Respiratory Disorders- Level 2

Respiratory Disorders

Asthma

Asthma: Diverse Disease

  • Characterized by a combination of bronchial hyperreactivity with reversible expiratory airflow limitation.

  • Signs and symptoms may vary.

  • Clinical course can be unpredictable.

  • Key features:

    • Inflammation

    • Airway obstruction

    • Normal lung function between attacks

Asthma: Common Triggers & Risk Factors

  • Nose & sinus problems

  • Allergens

  • Cigarette smoke

  • Air pollutants

  • Respiratory tract infections

  • Genetics

  • GERD

  • Drugs

  • Food additives

  • Exercise

  • Occupational factors

  • Psychological factors

Asthma: Pathophysiology

  • Main pathophysiologic process is inflammation.

  • Exposure to allergens or irritants triggers the inflammatory cascade involving a variety of inflammatory cells.

    • Leads to bronchospasm & mucus production.

  • Inflammation leads to:

    • Bronchoconstriction

    • Hyperresponsiveness

    • Edema of airways

  • Limited airflow results.

Asthma: Clinical Manifestations S/s

  • Wheezing

    • Most common during acute attacks.

    • Unreliable for determining severity.

  • Cough

  • Dyspnea- SOB

  • Chest tightness

  • Hyperinflation and prolonged expiration due to air trapping in narrowed airways.

  • ABG (Arterial Blood Gas) changes: alkalosis, then acidosis.

Asthma: Classifications

  • Classifications:

    • Intermittent

    • Mild persistent

    • Moderate persistent

    • Severe persistent

  • Severity is used to guide treatment decisions initially, then addresses level of control.

  • All patients should have an asthma action plan for acute attacks and to prevent future attacks.

  • Patient education is crucial.

Asthma: Complications- Red Flags (if we fail to rescue patient)

  • Ranges from mild to life-threatening.

  • Lasts from a few minutes to hours.

  • Patients are often asymptomatic between attacks.

  • Some patients experience more continuous symptoms.

  • Complications may include:

    • Pneumonia & worsened flu

    • Tension pneumothorax

    • Status asthmaticus

    • Acute respiratory failure

Asthma: Status Asthmaticus (Red Flag!!!)

  • Extreme acute asthma attack characterized by hypoxia, hypercapnia, and acute respiratory failure.

  • Hypercapnia- abnormally elevated level of CO2 in the blood

  • Life-threatening.

  • Bronchodilators and corticosteroids may not be effective.

  • Symptoms: chest tightness, increased shortness of breath, or a sudden inability to speak.

  • Without treatment, it leads to hypotension, bradycardia, respiratory failure, and cardiac arrest.

  • Emergency treatment:

    • Mechanical ventilation

    • Hemodynamic monitoring

    • Analgesia and sedation

    • IV magnesium sulfate

Asthma: Diagnostics

  • History & physical examination

  • Peak expiratory flow rate (PEFR)- reduced

  • Spirometry-

  • Allergy testing- positive IgE mediated response to specific response

Asthma: Interprofessional Care

  • Goals of treatment:

    • Achieve and maintain control

    • Return to daily functioning

Asthma: Drug Therapy

  • Medication guidelines are based on steps:

    • Symptoms worsen—step up medications

    • Symptoms controlled—step down medications

  • Asthma drugs divided into 2 general types:

    • Short term controller – "rescue" agents

    • Preferred reliever agents

Asthma: Drug Therapy - Inhaled Corticosteroids (ICS)

May not see effects until after two weeks of regular treatment!!!!

  • Examples:

  • “son”

  • fluticasone- have patient rinse mouth with agua or mouthwash to prevent oral thrush

  • Ciclesonide

  • Budesonide-

  • Mometasone

  • Triamcinolone

  • Beclomethasone

  • Flunisolide

  • First line agents

  • Most effective short term controller drugs for asthma

  • Anti-inflammatory

  • Also used as preferred reliever (preventative)

  • Side effects:

    • Easy bruising

    • ↓ bone density

    • Oropharyngeal candidiasis, hoarseness & dry cough

    • Cold symptoms, headache

Asthma: Drug Therapy - Bronchodilators

  • Short-acting inhaled β2-Adrenergic agonists (SABAs)

    • Example: albuterol

    • No longer first-line therapy in acute attacks, but still have a key role in management.

    • Onset: minutes

    • Duration: 4 to 8 hours

    • Used as alternate reliever medication when low-dose ICS ineffective

  • Long-acting inhaled β2-Adrenergic agonists (LABAs)

    • Examples: salmeterol, formoterol

    • Used only as an adjunct to treatment

    • Scheduled dosing 2x/day–every 12 hours

    • Combination therapy:

      • LABAs with ICS provides better asthma control.

      • Examples: fluticasone/salmeterol, budesonide/formoterol

  • Methylxanthines

    • Less effective long-term bronchodilator and used only as alternative.

    • Many drug interactions & side effects.

    • Narrow margin of safety—monitor blood levels.

    • Toxicity: nausea, vomiting, seizures, insomnia

  • Anticholinergic drugs: short & long-acting muscarinic antagonists (SAMAs & LAMAs)

    • Example: ipratropium, oxitropium (SAMA)

    • Tiotropium (LAMA)

    • Less effective than SABAs.

    • Not used in routine management, except for severe acute asthma attacks

Asthma: Drug Therapy - Leukotriene Modifiers

  • Example: montelukast

  • Produce bronchodilator and anti-inflammatory effects.

  • Preventative only.

Asthma: Inhalation Devices for Drug Delivery

  • Metered dose inhalers (MDI)

    • Small, hand-held, pressurized devices

  • Dry powdered inhaler (DPI)

    • Powdered medication; breath activated

  • Nebulizers

    • Machine converts drug solutions into a fine mist which is inhaled via face mask or mouthpiece

  • Patient education is essential for all devices.

Mild-Moderate vs. Severe Asthma

Feature

Mild-Moderate

Severe

Interference in ADLs

Minimal interference

Recurring symptoms interfere with ADLs

Mental Status

Alert, oriented, speaks in sentences

Alert and oriented but focused on breathing; Frightened, restless; agitated if hypoxemic

Symptoms

May have chest tightness and dyspnea

Tachycardia, tachypnea (>30 breaths/min)

Medication Use

Slight increased use of asthma meds

Accessory muscle use; sits forward

O2 saturation

> 90% on room air

Wheezing, possible silent chest

Treatment

Inhaled corticosteroids

Inhaled bronchodilators (nebulizer) and oral (or IV) corticosteroids; Supplemental O2 and oximetry; Monitor VS; Monitor ABGs, VS, WOB

Asthma: Additional Nursing Considerations - Health Promotion

  • Identify & avoid triggers & allergens

    • Environmental measures to reduce allergens

    • Inhaler before exercise if indicated

    • Warm clothing/scarf when cold

  • Preventative vaccines

  • Prompt Dx & treatment for upper respiratory infections and sinusitis

  • Healthy living

  • Stop smoking

  • Rescue inhaler at all times

Chronic Obstructive Pulmonary Disease (COPD)

COPD: Significance

  • Men > women

Chronic Obstructive Pulmonary Disease (COPD)

  • Progressive lung disease characterized by persistent airflow limitation.

    • Chronic enhanced inflammatory response in airways and lungs.

    • Exacerbations and other coexisting illness contribute to severity of the disease

COPD: Terms to Know

  • Chronic bronchitis—the presence of cough and sputum production for at least 3 months in each of 2 consecutive years

  • Emphysema—destruction of alveoli without fibrosis

  • Each of these are features of COPD

COPD: Risk Factors

  • Cigarette smoking

    • (> 40 years with >10 pack years smoking history?)

  • Infection

  • Asthma

  • Air pollution

  • Occupational dusts and chemicals

  • Aging

  • Genetics (including α1-Antitrypsin deficiency [AATD])

COPD: Pathophysiology

  • Characterized by chronic inflammation of:

    • Airways

    • Lung parenchyma

    • Pulmonary blood vessels

  • Defining feature: airflow limitation not fully reversible during forced exhalation due to:

    • Loss of elastic recoil

    • Airflow obstruction due to mucus hypersecretion, mucosal edema, and bronchospasm

COPD: Pathophysiology - Disease Progression

  • Disease progression is marked by worsening:

    • Abnormalities of airflow limitation

    • Air trapping

    • Gas exchange

  • Severe disease leads to:

    • Pulmonary hypertension- Pulmonary hypertension is a type of high blood pressure that specifically affects the arteries in the lungs and the right side of the heart

    • Systemic manifestations

  • Main characteristic of COPD is the inability to expire air.

COPD: Clinical Manifestations

  • Develops slowly

  • Diagnosis is considered when:

    • Chronic cough

      • Intermittent

      • First symptom

      • Sputum production

    • Dyspnea

    • History of exposure to risk factors

  • Late to Advanced Stages:

    • Chest breather (versus abdominal)

      • Use of accessory and intercostal muscles

      • Inefficient breathing

    • Wheezing & chest tightness

    • Fatigue

    • Weight loss & anorexia

    • Prolonged expiratory phase

    • Decreased breath sounds, wheezing

    • Barrel chest

    • Tripod position (Slide 39)

    • Pursed-lip breathing

    • Peripheral edema (ankles)

  • Advanced Stage:

    • Hypoxemia

      • PaO_2 < 60 mmHg

      • SaO_2 < 88\%

    • Hypercapnia

      • PaCO_2 > 45 mmHg

    • Bluish-red color of skin

COPD: Complications

  • Pulmonary hypertension

    • Pressure in the blood vessels leading from the heart to the lungs is too high.

    • ↑ right ventricle pressure

    • → Cor pulmonale (R ventricle enlargement)

      • Late manifestation, prognosis worsens

      • Dyspnea

      • S3 & S4, murmurs, bounding pulse, distended neck veins, hepatomegaly, peripheral edema, weight gain, crackles in bases

      • → R-sided heart failure

  • Acute exacerbations

    • Worsening of respiratory symptoms

      • ↑ dyspnea, ↑ sputum volume, ↑ sputum purulence, ↑ RR

      • Malaise, insomnia, fatigue, depression, confusion, decreased exercise tolerance, ↑ wheezing, fever

    • Common causes

      • Bacterial infections

      • Viral infections

    • Increase in frequency with disease progression

  • Treatment: acute exacerbation

    • Inpatient or outpatient (depends on severity)

    • Treatments

      • SABAs and oral corticosteroids

      • Other: anticholinergics, antibiotics, diuretics

      • Oxygen therapy

      • CPAP / BiPAP

  • RN assessment

    • Signs of increasing severity

      • Use of accessory muscles, central cyanosis, lower extremity edema, unstable BP, altered alertness

    • Risk for acute respiratory failure

      • Life threatening

      • Intubation & mechanical ventilation

    • Baseline vs Exacerbation:

      • pH: Normal to ↓ during baseline, ↓ from baseline during exacerbation.

      • PaO2: Normal to ↓ during baseline, ↓ from baseline during exacerbation. PaO2 < 60mmHg

      • PaCO2: Normal to ↑ during baseline, ↑ from baseline during exacerbation. PaCO2 > 45mmHg

COPD: Complications - Cor Pulmonale Treatment

COPD management:

  • Long-term low-flow O_2

  • Diuretics

  • Anticoagulation

COPD: Diagnostics

  • History & physical

  • Spirometry

  • Chest x-ray

  • Serum α1-Antitrypsin levels

  • 6-minute walk test

  • ABGs

COPD: Drug Therapy

  • Bronchodilators

    • Relax smooth muscle in the airway

    • Improve ventilation of the lungs

    • Decreased dyspnea

    • Inhaled route is preferred

    • Include:

      • β2-Adrenergic agonists

      • Anticholinergics

      • Methylxanthines

  • SABAs are a mainstay of treatment (albuterol)

  • LABAs are often used (salmeterol, formoterol)

  • Anticholinergics (SAMAs & LAMAs)

    • LAMA example: tiotropium bromide

  • Combo SABA with SAMA

    • Example: albuterol/ipratropium - nebulizer

    • Example: albuterol/ipratropium - inhalation spray

  • ICS usually combined with LABA

    • fluticasone/salmeterol

    • budesonide/formoterol

  • Inhaled long-acting anticholinergics (LAMAs), LABAs, & ICS all help reduce exacerbations

  • Many new drugs and delivery devices are currently being developed for the treatment of patients with COPD

COPD: Interprofessional Care

  • Oxygen therapy

    • Low vs high flow

    • NC- 1-6 L/min

    • Simple face mask- 5-8 L/min

    • Partial rebreather- 6-11 L/min

    • Nonrebreather mask- 10-15 L/min

    • Venturi mask- 4-10 L/min

    • Humidification

    • Combustion

    • O_2 toxicity

    • CO_2 narcosis

      • CO_2 no longer stimulus to breathe

      • Now with hypoxic drive – administer O_2 with care

    • Infection

    • Oxygen at home

  • Respiratory infection prevention

  • Smoking cessation

  • Tripod position

  • Pursed-lip breathing

  • Nutrition / Hydration

  • Exercise, Modify ADLs to conserve energy / O_2 use during ADLs

  • Quality of life / Palliative care / Hospice

Lung Cancer

Lung Cancer: Etiology

  • Smoking

    • Most important risk factor

    • 80-90% of cases

    • No safe tobacco

  • Smoking cessation (↓ risk)

  • Risk related to total exposure to tobacco smoke

  • Passive smoking is a risk

  • Other risk factors

    • Pollution

    • Radiation (radon gas)

    • Asbestos

    • Industrial agents

      • radon, coal dust, asbestos, chromium, silica, arsenic, diesel exhaust

Lung Cancer: Pathophysiology

  • Arise from mutated epithelial cells

  • Slow growth

  • Occur primarily in segmental bronchi & upper lobes

  • 2 broad categories

    • Non–small cell lung cancer (NSCLC); 84%

    • Small cell lung cancer (SCLC); 13%

  • Metastasis: lymph nodes, liver, brain, bones & adrenal glands

  • Paraneoplastic syndrome

    • Caused by hormones, cytokines, enzymes, or antibodies that destroy healthy cells

    • May manifest before cancer diagnosed

    • Associated most with SCLC

    • Examples: hypercalcemia, SIADH (Syndrome of Inappropriate Antidiuretic Syndrome), adrenal hypersecretion, polycythemia, Cushing’s syndrome

  • Risk Factors

  • · Behavioral Factors:

    o A long history of cigarette smoking (including secondhand smoke exposure).

    · Environmental/Occupational Exposures

    · Demographic Factors:

    o Increased risk with advancing age and a higher incidence among males.

    · Medical History

    · Genetic Susceptibility

Lung Cancer: Subtypes

  • Non-small Cell Lung Cancer (NSCLC)

    • Squamous cell carcinoma

      • Slow growing

      • Early symptoms: cough & hemoptysis

    • Adenocarcinoma

      • Moderate growing

      • Most common

    • Large-cell carcinoma

      • Rapid growing

      • Highly metastatic

  • Small Cell Lung Cancer (SCLC)

    • Very rapid growth

    • Most malignant

    • Early metastasis

    • Associated endocrine disorders

    • Chemotherapy

    • Radiation

    • Poor prognosis

Lung Cancer: Manifestations

  • Non-specific

  • Appear late

  • Masked by chronic cough

  • Depend on

    • Type of cancer

    • Location

    • Extent and location of mets

  • Persistent cough (most common)

  • Hemoptysis

  • Dyspnea

  • Wheezing

  • Chest pain

  • Pleural effusion

  • Later Manifestations:

    • Anorexia, nausea/vomiting, fatigue, weight loss

    • Hoarseness

    • Unilateral paralysis of diaphragm

    • Dysphagia

    • Superior vena cava obstruction

    • Palpable lymph nodes

    • Pericardial effusion

    • Cardiac tamponade

    • Dysrhythmias

Lung Cancer: Diagnostic Studies

  • Chest x-ray (1st)

  • Chest CT scan

  • Biopsy

  • Thoracentesis (if pleural effusion - pleural fluid analysis)

  • Bone scan / CT scan

  • MRI

  • PET scan

Treatment:

· Surgical Resection:

o For early-stage lung cancer, procedures such as lobectomy or pneumonectomy may be performed.

· Radiation Therapy

· Chemotherapy

· Targeted Therapy and Immunotherapy

Lung Cancer: Interprofessional Care

  • Surgery slide 67

    • Wedge resection- small portion of lobe removed

    • Segmental resection- about half of the lobe is removed

    • Lobectomy- entire lobe is remomved

    • Pneumonectomy- entire lung is removed

    • Video Assisted Thoracoscopic Surgery (VATS)

  • Thoracotomy—surgical incision into the chest

    • Median sternotomy—heart

    • Lateral thoracotomy—lungs

      • Wedge resections (lung cancer)

      • Posterolateral

      • Anterolateral

  • Video-assisted thoracic surgery (VATS)

    • Minimally invasive surgery

    • 2-D video image of inside chest cavity

    • Diagnosis & treatment

      • Lung cancer near outside of lungs

    • Advantages: less discomfort, reduced hospital stay, lower morbidity, fewer complications, faster return to normal activity

  • Radiation therapy

  • Stereotactic Body Radiotherapy (SBRT) or Stereotactic Radiosurgery (SRS)

    • High dose of radiation accurately delivered to tumor

    • Smaller part of healthy lung exposed

  • Chemotherapy

  • Targeted therapy

  • Immunotherapy

Lung Cancer: Nursing Management

  • Focus on: Care of patient with chest surgery

    • Respiratory

    • Cardiovascular

    • Infection

    • Wound care

    • Anxiety

    • Pain

  • Focus on:

    • Radiation & chemotherapy

    • Post-op ROM

    • Education

    • Health Promotion

    • Palliative care

    • Hospice

Head & Neck Cancer

Head & Neck Cancer

  • Structures include: nasal cavity, paranasal sinuses, nasopharynx, oropharynx, larynx, oral cavity & salivary glands

  • Squamous cells in mucosal surfaces

  • Etiology: tobacco

  • > 50yrs

  • Men > women

  • Additional risk factors

    • Alcohol use

    • HPV infection

    • Sun exposure

    • Asbestos exposure

    • Industrial carcinogens

    • Marijuana use

    • Radiation to head and neck

    • Poor oral hygiene

Head & Neck Cancer: Clinical Manifestations

  • Early symptoms

    • Vary by location

    • Pharyngeal: Lump in throat, sore throat

    • Laryngeal: hoarseness > 2 weeks

    • Other: white or red patches in mouth, change in voice, ear pain, ringing in ears, swelling or lump in neck, constant cough, coughing up blood, swelling in jaw

  • Late symptoms

    • Unintentional weight loss

    • Difficulty with chewing or swallowing

    • Trouble moving tongue or jaw

    • Trouble breathing

    • Airway obstruction (partial or full)

Complications:

· Local Tissue Destruction

· Metastasis

· Airway Compromise

Head & Neck Cancer: Diagnostic Studies

  • Physical assessment: ears, nose, throat, mouth & neck

  • Check for: thickening of oral mucosa, lymph nodes, leukoplakia, or erythroplakia

  • Pharyngoscopy and laryngoscopy (inspection and biopsies)

  • CT scan, MRI & PET scan

Head & Neck Cancer: Treatment Factors

  • TNM staging

  • Age & health

  • Urgency of treatment

  • Cosmetic & functional consideration

  • Patient choice

  • Treatment options: include surgery, radiation therapy, chemotherapy, targeted therapy, or any combination of these modalities

Head & Neck Cancer: Treatment

  • Surgery

    • Vocal cord stripping

    • Laser surgery

    • Cordectomy

    • Partial or total laryngectomy

    • Pharyngectomy

    • Lymph node removal

    • Neck dissection

    • Tracheostomy

    • Reconstructive procedures

  • Radiation therapy

  • Chemotherapy & targeted therapy

  • Nutritional therapy

    • Malnourished

    • Swallowing concerns

    • Chemo & radiation side effects

    • Gastrostomy tube & enteral feedings

  • Physical therapy

    • Strength, ROM, disability prevention

  • Speech therapy

Head & Neck Cancer: Nursing Management

  • Focus on: Care of patient with head & neck surgery

    • Airway

    • VS

    • Infection

    • Bleeding

    • Wounds, drains & tubes

    • Fluids & nutrition

  • Focus on

    • Aspiration risk

    • Pain

    • Radiation

      • Dry mouth, mucositis, skin, fatigue

      • Often used as an adjuvant treatment following surgery or as a primary treatment for unresectable tumors.

    • Difficulty coping

    • Impaired communication

    • Education

  • Health promotion (Preventative Measures)

    • Avoid tobacco

    • Avoid excess alcohol

    • Good oral hygiene

    • HPV prevention

Patient Education

o Provide education on the nature of the disease, treatment options, and the importance of adherence to therapy.

o Educate about potential side effects of surgery, radiation, and chemotherapy, including strategies for managing mucositis, xerostomia, and skin changes.

o Teach patients and families about airway clearance techniques and the use of oxygen therapy at home if prescribed.

Environmental Lung Disease

Environmental Lung Disease

  • AKA: Occupational lung disease

  • Inhalation of dust or chemicals

  • Lung damage depends on

    • Toxicity

    • Amount and duration of exposure

    • Susceptibility of individual

  • Pneumoconiosis

    • Inhaled mineral or metal dust particles

      • Silicosis

      • Asbestosis

      • Coal Workers Pneumoconiosis (Black Lung)

  • Chemical pneumonitis

    • Inhalation of toxic chemical tumes

  • Hypersensitivity pneumonitis (Extrinsic allergic alveolitis)

    • Inhalation of allergic antigens

      • Bird fancier’s lung

      • Farmer’s lung

Causes:

Occupational Exposures: Dust (silica, coal), asbestos fibers, metal fumes, and chemical irritants in industries such as mining, construction, or manufacturing.

Ambient Air Pollution: Exposure to vehicular emissions, industrial pollutants, and particulate matter in urban environments.

Chronic Exposure:

Long-term exposure leads to cumulative lung injury and inflammation.

Risk Factors:

Occupational Exposures:

Jobs with significant exposure to dust, chemicals, or industrial pollutants.

Environmental Factors:

Living in areas with high levels of air pollution.

Lifestyle Factors

Personal Health:

Preexisting respiratory or cardiovascular disease.

Age:

Older adults

Environmental Lung Disease: Manifestations

  • Manifestations (10-15 years post exposure)

    • Dyspnea, cough, wheezing & weight loss

    • Reduced lung capacity

    • Complications:

      • COPD

      • acute pulmonary edema, lung cancer, mesothelioma, TB, cor pulmonale

Environmental Lung Disease: Interprofessional & Nursing Care

  • Prevention

  • Regular check-ups

  • Acute care

  • Outpatient

  • O2 therapy

  • Patient repositioning and airway clearance- semi Fowler’s

  • Pulmonary Rehabilitation & activity

Treatment:

Medical Management

Surgery

  • in sever cases lung transplantation may be an option

Medical Treatment:

Bronchodilators and Corticosteroids:

May be used to reduce airway inflammation and improve airflow.

Prevention:

  • Removal from Exposure

  • Key to preventing further lung injury is reducing or eliminating exposure to the offending environmental agent.

Patient Education:

  • Exposure Avoidance:

    Teach patients how to avoid environmental triggers, including smoking cessation and minimizing exposure to pollutants.

    • Symptom Recognition:

    Educate on recognizing signs of worsening respiratory status (e.g., increased dyspnea, fatigue, cyanosis) and when to seek emergency care.

    • Home Oxygen Therapy:

    * Instruct on proper use, maintenance, and troubleshooting of oxygen therapy equipment if prescribed for home use.

    • Lifestyle Modifications:

    Encourage dietary adjustments, regular exercise, and adherence to medication regimens.

    • Emotional Support and Collaboration:

    Provide counseling to help patients cope with chronic illness.

    Collaborate with the interdisciplinary team (respiratory therapists, pulmonologists, occupational therapists) to create an individualized care plan.