Nursing Care of Clients with Upper Respiratory Disorders

Respiratory System Anatomy, Physiology, & Core Functions

• System Overview:

  • The respiratory system is split into two primary anatomical divisions: the upper respiratory tract and the lower respiratory tract.

  • Both tracts work in conjunction to achieve ventilation, defined as the physical movement of air into and out of the airways.

• Upper Respiratory Tract Anatomical Structures:

  • Nose and Nasal Passages:

    • Lined with ciliated mucous membranes.

    • Pathogens and bacteria captured in the mucus are destroyed by lysozymes.

    • Nostril tissue lining contains conchae (turbinates) responsible for thermoregulation, moistening, and cleansing incoming air.

  • Paranasal Sinuses:

    • Air-filled spaces within the facial bones.

    • Consists of four paired groups: frontal (above the eyes in the forehead bone), maxillary (in the cheekbones under the eyes), ethmoid (between the eyes and nose), and sphenoid (in the center of the skull behind the nose and eyes).

  • Pharynx (Throat):

    • Serves as a passageway for both air and swallowed food/water toward the esophagus.

    • Contains immunocompetent lymphoid tissues and nodes: pharyngeal, palatine, and lingual tonsils/adenoids.

  • Tonsils and Adenoids:

    • Protective lymphoid glands situated on both sides of the throat and posterior nasopharynx that form part of the body's immune defense against ingested or inhaled pathogens.

  • Larynx (Voice Box):

    • Connects the pharynx to the trachea.

    • Contains the true and false vocal cords, hyoid bone, thyrohyoid membrane, thyroid cartilage, vocalis muscle, cricoid cartilage, and ventricle.

    • Plays a critical protective role in preventing aspiration during swallowing via the epiglottis, a cartilage flap covered with mucous membrane.

• Lower Respiratory Tract Anatomical Structures:

  • Trachea (Windpipe):

    • Rigid tube that conducts air from the larynx down into the mainstem bronchi.

  • Lungs & Bronchial Tree:

    • Consists of the right bronchus, left bronchus, bronchioles, and terminal alveolar structures.

    • Right and left lungs are enveloped by the pleura and pleural space, resting on the diaphragm muscle.

  • Alveoli (Air Sacs):

    • Microscopic primary sites of gas exchange.

    • Surrounded by a dense capillary network connected to the pulmonary artery (carrying deoxygenated blood from the heart) and pulmonary vein (returning oxygenated blood to the heart).

    • Shifts $O_2$ from inspired air into the blood while shifting $CO_2$ from the capillary blood into the alveoli for expulsion.

• Core Physiological Functions:

  • Provides oxygen to the bloodstream and removes carbon dioxide.

  • Enables sound production and vocalization as expired air passes over the vocal cords.

  • Enables protective and reflexive non-breathing air movements (such as coughing and sneezing) to keep air passages clear.

  • Maintains control of systemic acid-base balance and blood pH.

Diagnostic Procedures in Respiratory Care

• Pulmonary Function Tests (PFTs):

  • Evaluates functional lung capacity by measuring airflow, lung volumes, and gas exchange.

  • Incentive Spirometry: The most common diagnostic/therapeutic PFT method. Involves forceful inhalation/exhalation into a mouthpiece attached to a spirometer to measure inspired and expired volume. Identifies obstructive patterns like asthma or COPD and encourages sustained maximal inspiration (SMI) to prevent atelectasis.

• Laboratory Blood Studies:

  • Complete Blood Count (CBC): Measures red blood cell count and hemoglobin concentration to determine the oxygen-carrying capacity of the blood.

  • Arterial Blood Gas (ABG) Studies:

    • Measures blood pH, arterial oxygen tension ($PaO_2$), and arterial carbon dioxide tension ($PaCO_2$).

    • $PaO_2$ indicates the degree of blood oxygenation.

    • $PaCO_2$ indicates the adequacy of alveolar ventilation.

• Sputum Studies:

  • Collected and analyzed to identify pathogenic micro-organisms (bacteria, fungi, viruses) and to check for the presence of malignant cells.

• Noninvasive & Imaging Procedures:

  • Pulse Oximetry: Noninvasive continuous monitor measuring arterial hemoglobin oxygen saturation ($SaO_2$ / $SpO_2$).

  • Chest X-Ray: Radiographic examination used to diagnose pulmonary conditions; routinely includes posterior-anterior (PA) and lateral views.

  • Computed Tomography (CT Scan): Cross-sectional imaging technique scanning the lungs in successive thin layers using a narrow x-ray beam to identify structural lesions.

• Invasive & Endoscopic Diagnostics:

  • Bronchoscopy: Direct visual inspection of the larynx, trachea, and bronchi using either a flexible fiberoptic bronchoscope or a rigid bronchoscope.

  • Thoracoscopy: Diagnostic endoscopic procedure allowing direct examination of the pleural cavity and pleural surfaces.

  • Thoracentesis: Diagnostic or therapeutic aspiration of fluid or air from the pleural space. Typically performed with the patient sitting upright and leaning forward over a bedside table; excess fluid is collected in a collection bag or syringe to relieve pulmonary compression.

Respiratory System Assessment Techniques

• Pre-Assessment Baseline:

  • Obtain complete vital signs prior to examination: temperature, pulse, respirations, blood pressure, and $SpO_2$ via pulse oximetry.

• Component 1: Inspection:

  • Nose: Assess for patency, inflammation, deformities, symmetry, and discharge. Occlude one nare at a time to test air patency. Tilt head back, gently elevate tip of nose, and inspect interior using a nasal speculum and adequate light source.

  • Mouth and Pharynx: Inspect interior mouth for mucosa color, lesions, masses, gum retraction, bleeding, and dentition. Check tongue symmetry. Depress middle-posterior tongue with a tongue blade to view pharynx; a normal gag response confirms intact Cranial Nerves IX (glossopharyngeal) and X (vagus).

  • Neck: Inspect symmetry and swellings. Palpate lymph nodes with patient erect and neck slightly flexed. Progress palpation sequentially: nodes around ears $\rightarrow$ base of skull $\rightarrow$ under angles of mandible $\rightarrow$ midline. Small, mobile, nontender nodes ("shotty nodes") are normal non-pathologic findings; tender, hard, or fixed nodes indicate pathology.

  • Thorax and Lungs:

    • Use anatomical reference lines to localize findings (e.g., $2\,\text{cm}$ from the right midclavicular line).

    • Perform all physical maneuvers (inspection, palpation, percussion, auscultation) completely on either the anterior or posterior chest before switching sides.

    • Position patient upright or with head of bed elevated (or leaning forward on bedside table).

    • Observe for respiratory distress (tachypnea, accessory muscle usage).

    • Assess chest symmetry and shape: Normal anteroposterior (AP) to transverse diameter ratio is $1:2$. An increased AP diameter (barrel chest) indicates lung hyperinflation or normal aging changes.

    • Inspect sternal shape: Pectus carinatum (prominent sternal protrusion) vs. Pectus excavatum (indentation of lower sternum above xiphoid process).

  • Respiratory Rate Assessment:

    • Normal adult rate: $12\text{ to }20\,\text{breaths/min}$.

    • Normal older adult rate: $20\text{ to }25\,\text{breaths/min}$.

    • Normal child rate: $25\text{ to }30\,\text{breaths/min}$.

  • Abnormal Breathing Patterns:

    • Kussmaul: Rapid, deep, hyperpneic breathing.

    • Cheyne-Stokes: Periodic breathing pattern featuring alternating periods of deep, rapid respirations and apnea.

    • Biot's (Ataxic): Irregular, disorganized breathing pattern with unpredictable periods of apnea every 4 to 5 cycles; indicates severe brainstem/medulla damage.

  • Skin & Distal Structures:

    • Cyanosis: Late indicator of severe hypoxemia. In dark-skinned clients, assess conjunctivae, lips, palms, and sublingual tissue.

    • Clubbing: Sign of chronic long-standing hypoxemia. Characterized by loss of the normal angle between nail base and fingernail (angle increases to $\ge 180^\circ$), with increased depth, bulk, and sponginess of the distal fingertip.

• Component 2: Palpation:

  • Tracheal Alignment: Place index fingers on both sides of trachea above the suprasternal notch and press gently backward. Normal position is midline.

    • Deviates away from side of lesion in: Tension pneumothorax, neck mass.

    • Deviates toward side of lesion in: Pneumonectomy, lobar atelectasis.

  • Chest Expansion Symmetry: Assessed at diaphragm level. Place thumbs along costal margin meeting at midline anteriorly; ask patient to inhale deeply. Normal thumb separation is $1\,\text{in}$ ($2.5\,\text{cm}$).

    • Unequal movement: Caused by atelectasis, pneumothorax, pleural effusion, or incisional pain (splinting).

    • Equal but diminished movement: Caused by hyperinflation (barrel chest, COPD), restrictive lung disease, or neuromuscular diseases (e.g., amyotrophic lateral sclerosis, spinal cord lesions).

    • Absent movement: Over pleural effusion, massive atelectasis, or pneumothorax.

  • Tactile Fremitus: Palpable chest wall vibrations during speech. Place palmar surface of hands with hyperextended fingers on chest wall while patient repeats "ninety-nine" in a deep, loud voice; compare side-to-side top to bottom.

    • Increased fremitus: Increased tissue density (pneumonia, consolidation, pulmonary edema).

    • Decreased fremitus: Decreased tissue density or barrier (pleural effusion, lung hyperinflation).

    • Absent fremitus: Complete blockage of air/vibration (pneumothorax, atelectasis).

• Component 3: Percussion:

  • Evaluates density and aeration of underlying lung tissues.

  • Anterior chest percussed top to bottom interspace by interspace in semi-sitting or supine position. Posterior percussed with patient leaning forward and arms crossed.

  • Percussion Tones:

    • Resonant: Clear, long, hollow tone heard over normal healthy lung tissue.

    • Hyperresonance: Loud, lower-pitched sound heard over hyperinflated lungs (COPD, acute asthma attack, pneumothorax, air trapping).

    • Tympany: Loud, drumlike, high-pitched empty quality heard over gas-filled stomach, intestine, or large pneumothorax.

    • Dullness: Medium-intensity, medium-pitch sound over dense or fluid-filled areas (top of liver, lobar pneumonia consolidation, pleural effusion).

    • Flatness: Soft, high-pitched, short-duration sound over extremely dense tissue lacking air (posterior chest below diaphragm level, muscle, bone).

• Component 4: Auscultation:

  • Instruct patient to breathe slowly and deeply through an open mouth. Auscultate systematically from apices to bases, comparing identical right and left locations over lung tissue (avoiding bones).

  • Normal Breath Sound Categories:

    • Vesicular: Soft, low-pitched, gentle rustling sound heard over all peripheral lung fields except main bronchi. Inspiratory to expiratory phase ratio is $3:1$ (inspiration 3 times longer than expiration).

    • Bronchovesicular: Medium pitch and moderate intensity. Heard anteriorly over mainstem bronchi (adjacent to upper sternum) and posteriorly between scapulae. Ratio is $1:1$ (inspiration equals expiration).

    • Bronchial: Loud, high-pitched, tubular quality. Heard directly over the trachea in the neck. Ratio is $2:3$ with a noticeable silence/pause between inspiration and expiration.

  • Adventitious (Abnormal) Breath Sounds:

    • Fine Crackles: Discontinuous, high-pitched, short popping sounds heard near end of inspiration. Caused by sudden snapping open of collapsed alveoli or terminal bronchioles. Sound mimics rolling hair strands between fingers near ear. Associated with idiopathic pulmonary fibrosis, early pulmonary edema, pneumonia, atelectasis, early heart failure.

    • Coarse Crackles: Discontinuous, low-pitched, longer bubbling/gurgling sounds on inspiration and sometimes expiration. Caused by air passing through airways intermittently occluded by fluid, mucus, or mucosal folds. Mimics blowing through a straw underwater. Associated with heart failure, severe pulmonary edema, fluid-congested pneumonia, COPD.

    • Rhonchi: Continuous, low-pitched, rumbling, snoring, or rattling musical sounds. Caused by fluid or mucosal obstruction in large central airways. Prominent on expiration; frequently changes or clears following coughing or airway suctioning. Associated with COPD, cystic fibrosis, pneumonia, bronchiectasis.

    • Wheezes: Continuous, high-pitched squeaking or musical whistle sounds. Caused by rapid airflow through narrowed bronchial passages. First heard on expiration; progresses to inspiration as airway obstruction worsens. Associated with asthma bronchospasm, COPD, foreign body obstruction, tumor.

    • Stridor: Continuous, harsh, high-pitched, constant-pitch musical/crowing sound audible on inspiration. Caused by severe upper airway obstruction of the larynx or trachea. Associated with croup, epiglottitis, post-extubation vocal cord edema, foreign body aspiration. Medical emergency.

    • Absent Breath Sounds: Complete lack of audible air movement over lung field. Associated with massive pleural effusion, complete mainstem bronchus obstruction, large atelectasis, pneumonectomy.

  • Vocal Resonance Auscultation Tests:

    • Egophony: Auscultated vocal sound where spoken "E" is heard as a nasal "A" over areas of pulmonary consolidation or pleural effusion due to enhanced high-frequency sound transmission.

    • Bronchophony: Abnormal increase in clarity and loudness of spoken "ninety-nine" heard through stethoscope over consolidated lung tissue.

    • Whispered Pectoriloquy: Abnormal exaggerated transmission where a softly whispered phrase ("one-two-three") is heard loudly and clearly through the stethoscope over consolidated tissue (e.g., pneumonia).

Respiratory Terminology & Glossary

• Apnea: Temporary cessation of spontaneous breathing.

• Bronchophony: Abnormal increase in clarity of transmitted voice sounds heard when auscultating consolidated lung tissue.

• Bronchoscopy: Direct visual examination of larynx, trachea, and bronchi using an endoscope.

• Cilia: Microscopic, fine hair-like projections that provide a constant whipping motion to propel mucus and foreign debris away from lungs toward larynx.

• Compliance: Measure of the elastic force and ease required to expand or inflate the lungs.

• Crackles: Soft, high-pitched, discontinuous popping sounds heard during inspiration caused by delayed reopening of collapsed airways.

• Dyspnea: Subjective symptom describing difficult, uncomfortable, or shortness of breath.

• Egophony: Abnormal vocal sound conversion (spoken "E" heard as "A") during lung auscultation over consolidated tissue.

• Fremitus: Palpable vibrations produced by vocalization transmitted through the tracheobronchial tree to the chest wall.

• Hemoptysis: Expectoration of blood or blood-tinged sputum originating from the respiratory tract.

• Hypoxemia: Abnormal decrease in arterial oxygen tension ($PaO_2$) in the blood.

• Hypoxia: Deficiency of oxygen delivery or utilization at the cellular and tissue level.

• Obstructive Sleep Apnea: Temporary cessation of breathing during sleep caused by transient upper airway collapse or obstruction.

• Orthopnea: Inability to breathe comfortably except in an upright sitting or standing position.

• Oxygen Saturation: Percentage of total hemoglobin binding sites occupied by oxygen molecules ($SaO_2$ / $SpO_2$).

• Physiologic Dead Space: Anatomical and alveolar space in the respiratory tract that receives ventilation but does not participate in gas exchange.

• Pulmonary Diffusion: Passive movement of oxygen and carbon dioxide molecules across the alveolar-capillary membrane from areas of high concentration to low concentration.

• Pulmonary Perfusion: Flow of blood through the pulmonary capillary bed.

• Respiration: Gas exchange process between atmospheric air and blood, and between blood and body cells.

• Rhonchi: Low-pitched, continuous snoring or rattling sound associated with partial large airway obstruction.

• Stridor: Harsh, high-pitched continuous sound heard on inspiration caused by acute upper airway obstruction.

• Tachypnea: Abnormally rapid breathing rate.

• Tidal Volume: Volume of air inspired and expired with each normal resting breath.

• Ventilation: Mechanical movement of air into and out of the lungs/airways.

• Wheezes: Continuous high-pitched musical sounds caused by airway narrowing or partial obstruction.

• Whispered Pectoriloquy: Distinct, clear transmission of whispered words ("one-two-three") heard on thoracic auscultation.

Oxygen Therapy & Oxygen Administration Systems

• Principles and Goals:

  • Oxygen therapy is the administration of oxygen at concentrations greater than atmospheric room air (>21\% at sea level).

  • Goal: Provide adequate oxygen transport in blood, decrease the work of breathing, and reduce myocardial workload/stress.

  • Oxygen is classified as a medication and requires a physician's prescription except in emergency situations.

  • Tissue oxygen transport depends on cardiac output, arterial oxygen content, hemoglobin concentration, and metabolic demand.

• Clinical Indications & Assessment:

  • Changes in respiratory rate or pattern are the earliest clinical indicators of hypoxemia/hypoxia.

  • Need for oxygen is evaluated using ABG values, pulse oximetry ($SpO_2$), and targeted clinical physical assessment.

• Signs & Symptoms of Hypoxemia & Hypoxia:

  • Early Mental Status Changes: Impaired judgment, agitation, disorientation, confusion, lethargy, progressing to coma.

  • Systemic Manifestations: Dyspnea, elevated blood pressure, heart rate changes, cardiac dysrhythmias, diaphoresis, cool pale extremities.

  • Late Manifestation: Central cyanosis.

  • Chronic Longstanding Hypoxia (COPD, Chronic Heart Failure): Progressive fatigue, drowsiness, apathy, inattentiveness, delayed reaction times.

• Four Primary Types of Hypoxia:

  1. Hypoxemic Hypoxia:

     • Decreased arterial blood oxygen content resulting in reduced tissue diffusion.

     • Causes: Hypoventilation, high altitude, ventilation-perfusion ($V/Q$) mismatch (e.g., pulmonary embolism), pulmonary shunting (collapsed alveoli from atelectasis), diffusion barrier defects.

     • Correction: Administer supplemental $O_2$ or increase alveolar ventilation.

  2. Circulatory Hypoxia:

     • Inadequate tissue oxygenation resulting from reduced tissue capillary perfusion.

     • Causes: Decreased cardiac output, local vascular arterial obstruction, low-flow shock states, cardiac arrest.

     • Correction: Identify and treat underlying hemodynamic cardiac/circulatory failure.

  3. Anemic Hypoxia:

     • Decreased effective hemoglobin concentration causing reduced oxygen-carrying capacity of blood.

     • Rarely presents with true arterial hypoxemia ($PaO_2$ remains normal).

     • Carbon monoxide poisoning causes functional anemic hypoxia by binding hemoglobin and preventing oxygen carriage.

  4. Histotoxic Hypoxia:

     • Occurs when cellular metabolic poisons (e.g., cyanide) prevent peripheral tissues from utilizing delivered oxygen.

• Complications of Supplemental Oxygen:

  • Oxygen Toxicity:

    • Occurs when high concentrations of oxygen (>50\%) are administered for extended durations (>48\,\text{hours}).

    • Caused by excessive production of oxygen free radicals (metabolic byproducts) that damage alveolar epithelium and destroy cells.

    • Defensive antioxidants: Vitamin E, Vitamin C, beta-carotene.

    • Signs/Symptoms: Substernal chest discomfort, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory distress, alveolar infiltrates on chest x-ray.

  • Suppression of Ventilation (Hypoxic Drive):

    • In severe COPD, chronic hypercapnia blunts normal $CO_2$ respiratory stimulation; breathing drive becomes dependent on arterial hypoxemia.

    • Administering high $FiO_2$ removes hypoxic drive, causing progressive hypoventilation, rising $PaCO_2$, $CO_2$ narcosis, severe acidosis, and respiratory failure.

    • Prevention: Deliver low-flow oxygen ($1\text{ to }2\,\text{L/min}$).

  • Fire Danger: Oxygen supports active combustion. Post mandatory "No Smoking" warnings.

  • Infection Control: Equipment and tubing harbor bacteria; change delivery systems per infection control protocols.

• Oxygen Delivery Equipment & Classification:

  • Dispensed from cylinders or piped wall systems via pressure reduction gauges and flowmeters ($\text{L/min}$).

  • High flow rates require inline water bubble humidification to prevent drying mucosal linings.

  • Low-Flow Systems (contribute partially to inspired gas; $FiO_2$ fluctuates with patient's respiratory depth/rate):

    • Nasal Cannula:

      • Low-flow rate: $1\text{ to }6\,\text{L/min}$.

      • Delivers $FiO_2$ of $25\%\text{ to }40\%$.

      • High-flow nasal cannula (HFNC): Delivers up to $60\,\text{L/min}$ with heated humidification ($FiO_2$ up to $100\%$).

    • Simple Face Mask:

      • Flow rate: $6\text{ to }10\,\text{L/min}$.

      • Delivers $FiO_2$ of $35\%\text{ to }50\%$

      • Used when higher oxygen concentration than cannula is required for moderate oxygen deficits.

  • High-Flow Systems (delivers total inspired air at precise constant $FiO_2$ regardless of patient breathing pattern):

    • Venturi Mask:

      • Flow rate: $3\text{ to }10\,\text{L/min}$.

      • Delivers precise, fixed $FiO_2$ of $24\%\text{ to }60\%$

      • Utilizes the Venturi principle entraining room air with fixed oxygen streams; ideal for COPD.

    • Partial Rebreather Mask:

      • Flow rate: $8\text{ to }11\,\text{L/min}$.

      • Delivers $FiO_2$ of $50\%\text{ to }75\%$

      • Has a reservoir bag without one-way valves; patient reinhales initial portion of expired gas.

    • Non-Rebreather Mask:

      • Flow rate: $10\text{ to }15\,\text{L/min}$.

      • Delivers high $FiO_2$ of $80\%\text{ to }90\%$ (up to $100\%$

      • Equipped with one-way valves between mask, reservoir bag, and exhalation ports to prevent rebreathing room or exhaled air. Used in emergency resuscitation.

    • Transtracheal Catheter: Inserted surgically directly into trachea via neck incision for continuous low-dose delivery.

    • Aerosol Mask: Delivers humidified air mixtures or inhaled medications.

    • Tracheostomy Mask/Collar: Custom mask placed over a tracheostomy stoma.

    • T-Piece: Connects directly to tracheostomy/ET tube; can incorporate positive end-expiratory pressure (PEEP) valves.

    • Face Tent: Loose-fitting shield under chin for clients requiring high humidity who cannot tolerate tight masks (facial trauma, burns, claustrophobia).

Respiratory Self-Care, Breathing Retraining, & Airway Clearance

• Incentive Spirometry (Sustained Maximal Inspiration):

  • Method of deep breathing providing visual feedback.

  • Encourages client to maximize lung inflation, open collapsed alveoli, and prevent or reduce atelectasis.

• General Breathing Exercises:

  • Breathe slowly and rhythmically to empty lungs fully during exhalation.

  • Inhale through nose to warm, filter, and humidify air.

  • Prolong exhalation phase if feeling breathless.

  • Maintain ambient moisture using home humidifiers.

• Diaphragmatic Breathing Technique:

  • Goal: Strengthen the diaphragm and reduce respiratory effort.

  • Procedure:

    1. Place one hand on the abdomen (below costal margin) and the other on the mid-chest to monitor diaphragmatic movement.

    2. Inhale slowly and deeply through the nose, allowing the abdomen to protrude outwards as far as possible.

    3. Exhale slowly through pursed lips while contracting abdominal muscles, pressing firmly inward and upward on the abdomen.

    4. Perform continuously for 1 minute, followed by 2 minutes of rest.

    5. Gradually increase duration up to 5 minutes per session, repeated several times daily (before meals and at bedtime).

• Pursed-Lip Breathing Technique:

  • Goal: Prolong exhalation, increase intratracheal pressure, prevent airway collapse, and reduce trapped air/resistance.

  • Procedure:

    1. Inhale through the nose while counting slowly to 3 ("Smell a rose").

    2. Exhale slowly and evenly against pursed lips while contracting abdominal muscles.

    3. Count slowly to 7 during exhalation ("Blow out the candle").

    4. Sitting position: Fold arms over abdomen, inhale to count of 3, bend forward and exhale through pursed lips to count of 7.

• Chest Physiotherapy (CPT):

  • Includes postural drainage, chest percussion, vibration, and breathing retraining combined with effective coughing.

  • Postural Drainage (Segmental Bronchial Drainage): Uses specific gravitational positioning to drain secretions from bronchial branches into central bronchi/trachea for removal via coughing or suctioning.

  • Percussion and Vibration: Manual rhythmic cupped-hand clapping (percussion) or compression vibration over chest segments (or high-frequency chest wall oscillation [HFCWO] vest) to loosen thick adherent bronchial secretions.

Airway Management & Thoracic Surgical Interventions

• Airway Interventions:

  • Emergency Management: Quick relief of acute upper airway obstructions.

  • Endotracheal Intubation: Placement of an endotracheal tube through the nose or mouth into the trachea to secure an open airway.

  • Tracheostomy: Surgical creation of an opening into the trachea (tracheotomy) with insertion of an indwelling tracheostomy tube to bypass upper airway obstruction or facilitate long-term mechanical ventilation.

  • Mechanical Ventilation: Positive pressure ventilation required to control patient respirations during surgery, provide oxygenation when ventilatory effort fails, or rest fatigued respiratory muscles.

• Thoracic Surgical Procedures:

  • Pneumonectomy: Surgical excision of an entire lung, primarily performed for widespread bronchial carcinoma.

  • Lobectomy: Surgical removal of a single lobe of a lung when pathology is localized.

  • Segmentectomy (Segmental Resection): Removal of a specific bronchopulmonary segment (independent functional anatomical subdivisions of lung lobes).

  • Wedge Resection: Excision of a small localized, well-circumscribed lung lesion without matching intersegmental anatomical boundaries.

  • Bronchoplastic / Sleeve Resection: Excision of an infected/diseased lobar bronchus along with a section of the main stem bronchus, followed by re-anastomosis.

  • Lung Volume Reduction: Surgical removal of $20\%\text{ to }30\%$ of hyperinflated, diseased lung tissue (via midsternal incision or video thoracoscopy) to improve mechanical efficiency in emphysema.

  • Video Thoracoscopy: Minimally invasive endoscopic thoracic procedure allowing direct visualization without a thoracotomy incision; used for tissue biopsies, treating recurrent spontaneous pneumothorax, and evaluating pleural effusions or masses.

• Postoperative Care & Complications:

  • Postoperative mechanical ventilation support as needed.

  • Chest drainage system: Insertion of chest tubes connected to closed underwater seal drainage to drain blood, fluid, and air ($1523$ excess air/fluid) and re-expand lungs.

  • Pain management, early mobilization, and shoulder range-of-motion exercises.

  • Postoperative Complications: Respiratory distress, cardiac dysrhythmias, pneumothorax, bronchopleural fistula, acute hemorrhage, and hypovolemic shock.

Rhinitis & Nasal Disorders

• Rhinitis Overview:

  • Inflammation and edema of the nasal mucous membranes.

  • Symptoms: Watery rhinorrhea, nasal congestion/stuffiness, sneezing, postnasal drip.

• Allergic Rhinitis:

  • Inflammatory nasal reaction mediated by allergen-specific IgE responses.

  • Classification: Seasonal vs. Perennial; or by frequency: Episodic (sporadic exposure to non-environment allergens like animal dander), Intermittent (<4\,\text{days/week} or <4\,\text{weeks/year}), Persistent (>4\,\text{days/week} and >4\,\text{weeks/year}).

  • Pathophysiology Cascade:

    1. Inhaled allergens enter the nasal cavity.

    2. Allergens bind and cross-link allergen-specific IgE antibodies pre-attached to tissue mast cells.

    3. Mast cell degranulation releases primary chemical mediators: Histamine (vasodilation, increased capillary permeability), Leukotrienes (increased vascular secretions), Prostaglandins (increased mucus production), and Cytokines.

    4. Immediate response: Nasal mucosal edema, airway obstruction, watery rhinorrhea, sneezing reflex, nasal pruritus.

    5. Late-Phase Reaction ($4\text{ to }8\,\text{hours}$ post-exposure): Infiltration of inflammatory cells (eosinophils, neutrophils) causing chronic tissue swelling and congestion.

  • Cardinal Diagnostic Symptoms (Presence of 2 or more symptoms lasting $\ge 1\,\text{hour}$ on most days confirms high probability):

    1. Watery rhinorrhea.

    2. Sneezing.

    3. Nasal obstruction/blockage.

    4. Nasal pruritus (itching).

  • Physical examination shows pale, boggy, swollen nasal turbinates.

  • Diagnostic Allergy Tests: Skin prick/scratch/intradermal testing; Serum specific IgE Radioallergosorbent test (RAST); Multiple Allergen Simultaneous Test (MAST) using photoreagents on blood samples.

  • Pharmacotherapy:

    • Oral Antihistamines: Second-generation non-sedating H1-receptor antagonists: Loratadine ($10\,\text{mg}$ once daily), Desloratadine ($5\,\text{mg}$ once daily), Cetirizine ($10\,\text{mg}$ once daily or $5\,\text{mg}$ BID), Levocetirizine ($5\,\text{mg}$ once daily in evening).

    • Intranasal Corticosteroids: Potent local inhibitors of late-phase allergic inflammation: Beclomethasone dipropionate (2 sprays in each nare daily), Fluticasone / Flonase (1 to 2 sprays in each nare daily).

    • Decongestants: Oxymetazoline nasal spray; Oral Pseudoephedrine ($60\,\text{mg}$ every 4-6 hours, $120\,\text{mg}$ ER every 12 hours, or $240\,\text{mg}$ ER daily). Swallow extended-release formulations whole; do not crush or chew.

    • Antitussives: Suppress dry, non-productive coughing by blocking the central cough reflex in the brainstem (Dextromethorphan, Butamirate, Codeine).

    • Expectorants: Thin and liquefy thick mucus to aid expectoration in productive wet coughs (Guaifenesin, Bromhexine, Ambroxol).

• Non-Allergic Rhinitis:

  • Nasal inflammation not mediated by IgE or allergic mechanisms.

  • Triggers: Environmental pollutants, cigarette smoke, strong chemical odors, alcohol, cold dry air, anatomical nasal blockages (deviated septum), or rebound congestion from overuse of topical nasal decongestants (rhinitis medicamentosa).

• Acute Viral Rhinitis (Common Cold / Acute Coryza):

  • Upper respiratory infection caused by over 200 distinct viruses (rhinovirus is the most common cause).

  • Self-limiting; symptoms persist 2 to 14 days with full recovery typically in 7 to 10 days.

  • Caution: Limit topical nasal decongestant spray usage to a maximum of 3 consecutive days to prevent severe rebound nasal congestion (rhinitis medicamentosa).

  • Complications: Pharyngitis, sinusitis, otitis media, tonsillitis, lower respiratory tract infections.

  • Antibiotics are contraindicated unless secondary bacterial infection develops (indicated by fever >100.4^\circ\text{F} [$38^\circ\text{C}$], severe sinus/ear pain, tender swollen glands, or lack of improvement after 10 to 14 days).

• Nasal Polyps:

  • Definition: Benign, edematous, hypertrophied, pedunculated mucosal growths originating from the nasal or paranasal sinus mucosa.

  • Epidemiology: Common in adults, rare in children; 4 times higher incidence in males.

  • Risk Factors: Chronic mucosal inflammation (asthma, allergic rhinitis, chronic sinusitis, cystic fibrosis).

  • Clinical Manifestations: Smooth, glossy, bluish nasal projections (can exceed grape size), chronic nasal congestion, clear rhinorrhea, altered speech resonance, hyposmia (reduced smell), or anosmia (loss of smell).

  • Anatomical Subtypes:

    • Antrochoanal Polyps: Single, unilateral, originating from maxillary sinus; seen predominantly in children.

    • Ethmoidal Polyps: Multiple, bilateral, originating from ethmoid air cells; seen predominantly in adults.

  • Medical Management: Intranasal corticosteroid sprays or direct intralesional steroid injections to reduce size; oral antibiotics (amoxicillin, erythromycin) if secondary bacterial infection is present.

  • Surgical Management: Polypectomy using a nasal snare and removal forceps under local anesthesia; or Caldwell-Luc operation (surgical procedure designed by George Caldwell and Guy Luc to remove chronic diseased polypoid tissue from the maxillary sinus via an incision in the upper gum).

  • Postoperative Nursing Care (Nasal Polypectomy):

    • Position head of bed elevated $30^\circ\text{ to }45^\circ$ to minimize venous pressure, congestion, and edema. Maintain upright posture; avoid bending forward.

    • Monitor vital signs; observe for frequent swallowing (key sign of covert posterior nasal bleeding).

    • Apply ice packs over nasal bridge and cheeks ($20\text{ to }30\,\text{minutes}$ every hour for the first 24 hours).

    • Instruct client to spit out blood/mucus rather than swallowing (prevents gastric irritation and nausea).

    • Do not pull or manipulate nasal packing.

    • Administer analgesics (paracetamol/acetaminophen) as prescribed.

    • Provide cool mist humidification.

    • Critical Patient Discharge Restrictions: Absolutely NO nose blowing for $5\text{ to }7\,\text{days}$. Sneeze with MOUTH OPEN to prevent high pressures. Avoid strenuous activity, heavy lifting, straining, hot showers, hot beverages, and spicy foods (prevents vasodilation and secondary hemorrhage).

• Epistaxis (Nosebleed):

  • Distribution: Bimodal peak (children 2 to 10 years and adults over 50 years).

  • Etiology: Low humidity, allergies, upper respiratory infections, sinusitis, nasal trauma, foreign bodies, hypertension, chemical irritants, decongestant overuse, facial/nasal surgery, anatomic malformations, vascular tumors, bleeding disorders, and anticoagulant/antiplatelet medications (aspirin, NSAIDs, warfarin).

  • First-Aid Nursing Management:

    1. Keep the patient quiet and calm.

    2. Position patient sitting upright, leaning slightly forward with head tilted forward (prevents blood swallowing and aspiration).

    3. Apply firm continuous direct pressure by pinching the soft lower portion of the nose against the nasal septum for $10\text{ to }15\,\text{minutes}$.

    4. If bleeding persists beyond $15\text{ to }20\,\text{minutes}$, emergency medical intervention is required.

  • Medical & Hemostatic Interventions:

    • Apply topical vasoconstrictors (oxymetazoline, phenylephrine).

    • Insert cotton pledgets soaked in local anesthetic (lidocaine) and/or vasoconstrictors (epinephrine) into the nasal cavity for $10\text{ to }15\,\text{minutes}$.

    • Chemical cauterization using silver nitrate sticks, or thermal electrocautery.

    • Nasal Packing: Sponges (Merocel) or Epistaxis Balloons (Rapid Rhino).

    • Rapid Rhino Protocol: Soak device in sterile water for FULL 30 seconds $\rightarrow$ Insert along superior aspect of hard palate until blue indicator passes nares $\rightarrow$ Inflate balloon using a $20\,\text{mL}$ syringe with AIR ONLY until pilot cuff is rounded and firm $\rightarrow$ Reassess in $15\text{ to }20\,\text{minutes}$ $\rightarrow$ Tape catheter to cheek away from upper lip $\rightarrow$ Deflate and remove in $24\text{ to }72\,\text{hours}$.

    • Monitoring: Patients with posterior nasal packing require mandatory admission to a monitored step-down/telemetry unit to monitor respiratory rate, $SpO_2$, heart rate, rhythm, and signs of aspiration or hypoxia.

    • Provide pain medication prior to packing removal. Following removal, gently cleanse nares and apply water-soluble lubricating jelly.

    • Post-Epistaxis Instructions: Avoid vigorous nose blowing, strenuous exercise, heavy lifting, and straining for $4\text{ to }6\,\text{weeks}$. Use saline sprays and humidifiers. Sneeze with mouth open. Avoid aspirin and NSAIDs.

Sinusitis

• Pathophysiology & Overview:

  • Acute or chronic inflammatory disease affecting the mucosa of one or more paranasal sinuses.

  • Complicates $5\%\text{ to }10\%$ of upper respiratory infections in children. Maxillary and ethmoid sinuses are most frequently involved.

  • Pathophysiologic Process: Trigger (virus, allergy, anatomic defect, rapid barometric changes, dental infection) causes mucosal inflammation and edema $\rightarrow$ obstruction of sinus ostia $\rightarrow$ impaired mucociliary clearance $\rightarrow$ bacterial retention and pus accumulation $\rightarrow$ severe pressure build-up, facial pain, nasal congestion, and purulent postnasal discharge.

• Classification by Duration:

  • Acute Sinusitis: Symptoms last longer than 10 days but less than 30 days.

  • Subacute Sinusitis: Symptoms persist longer than 30 days without clinical improvement.

  • Chronic Sinusitis: Symptoms persist longer than 120 days.

• Predisposing Risk Factors:

  • Allergies, cold exposure, high pollen counts, daycare attendance, household tobacco smoke, recurrent sibling infections, anatomical defects (septal deviation, polyps), and mucociliary dysfunction (cystic fibrosis, immotile cilia syndrome).

• Clinical Manifestations:

  • Facial pressure, congestion, pain, headache, fatigue, purulent nasal discharge, cough, and fever.

  • Anatomical Pain Localization:

    • Maxillary Sinusitis: Pain over the cheeks and upper molar teeth.

    • Ethmoid Sinusitis: Pain localized between and behind the eyes.

    • Frontal Sinusitis: Pain localized across the lower forehead.

• Diagnostics:

  • Physical examination, sinus transillumination, sinus aspirate cultures, and nasal endoscopy.

  • Recurrent or chronic cases evaluated via sinus x-rays, CT scan (gold standard), or MRI.

• Non-Pharmacologic & Supportive Care:

  • Maintain high fluid intake ($6\text{ to }10\,\text{glasses}$ of water daily).

  • Steam inhalations and hot facial moist compresses.

  • Nasal saline irrigation lavage ($\frac{1}{4}\,\text{tsp}$ salt dissolved in $1\,\text{cup}$ warm water).

  • Elevate head of bed during rest; avoid exposure to tobacco smoke or dry cold air.

• Pharmacotherapy:

  • First-Line Antibiotics: Amoxicillin ($1.5\text{ to }3.5\,\text{g/day}$ divided 2 to 3 times daily); or Trimethoprim-Sulfamethoxazole ($800/160\,\text{mg}$ twice daily).

  • Second-Line Antibiotics: Amoxicillin-Clavulanate ($500/125\,\text{mg}$ three times daily); Cefuroxime ($250\text{ or }500\,\text{mg}$ twice daily); Doxycycline ($200\,\text{mg}$ on day 1, then $100\,\text{mg}$ twice daily for 2 to 10 days).

  • Macrolides: Clarithromycin ($500\,\text{mg}$ twice daily); Azithromycin ($500\,\text{mg}$ daily for 5 days).

  • Fluoroquinolones: Ciprofloxacin ($500\,\text{mg}$ twice daily); Levofloxacin ($500\,\text{mg}$ once daily).

  • Adjuvants: Oral Loratadine ($10\,\text{mg}$ daily); Topical Xylometazoline decongestant spray (2 to 3 sprays every 8 to 10 hours); Intranasal Fluticasone spray ($200\,\mu\text{g}$ daily); Acetaminophen or Ibuprofen for pain/fever.

Tonsillitis & Pharyngitis

• Tonsillitis:

  • Definition: Acute inflammation of the pharyngo-tonsillar lymphoid tissue and mucosa.

  • Epidemiology: Occurs at all ages, but highest frequency in children aged 5 to 10 years.

  • Etiology:

    • Viral: Rhinovirus, adenovirus, influenza, parainfluenza, Coxsackie, Epstein-Barr virus.

    • Bacterial: Group A beta-hemolytic Streptococcus (GABHS), Neisseria gonorrhoeae, Corynebacterium diphtheriae.

    • Fungal/Spirochetal: Candida species, Treponema pallidum.

  • Pathophysiology: Pathogen invades tonsillar crypt epithelium $\rightarrow$ immune system activation $\rightarrow$ lymphocyte proliferation (tonsillar enlargement) $\rightarrow$ mucosal vasodilation (intense redness) $\rightarrow$ accumulation of leucocyte exudative debris (white-yellow focal spots/exudates) $\rightarrow$ severe odynophagia and systemic fever.

  • Clinical Manifestations: Severe throat pain, difficult swallowing (odynophagia), systemic fever up to $104^\circ\text{F}$ ($40^\circ\text{C}$), enlarged red tonsils covered in exudate, anterior cervical lymphadenopathy, headache, ear pain, vomiting, refusal to eat, and potential scarlet fever rash.

  • Diagnostic Testing: Visual inspection, rapid streptococcal antigen test (RSAT) via throat swab, throat culture, and CBC.

  • Supportive Care: Bed rest until febrile phase resolves; high fluid intake and liquid nutrition (milkshakes, soups).

  • Antibiotic Regimens (GABHS):

    • Penicillin V: Children <12\,\text{years} (<27\,\text{kg}): $250\,\text{mg}$ every 12 hours for 10 days. Adults/children >12\,\text{years} (>27\,\text{kg}): $500\,\text{mg}$ every 12 hours for 10 days.

    • Penicillin G Benzathine: Single IM dose. <12\,\text{years} (<27\,\text{kg}): $600,000\,\text{UI}$. >12\,\text{years} (>27\,\text{kg}): $1,200,000\,\text{UI}$.

    • Amoxicillin: $50\,\text{mg/kg/day}$ divided every 12 to 24 hours for 10 days (max $500\,\text{mg}$ twice daily or $1\,\text{g}$ daily).

    • Azithromycin: $20\,\text{mg/kg/day}$ once daily for 3 days (max $500\,\text{mg/day}$).

    • Clindamycin: $20\text{ to }30\,\text{mg/kg/day}$ divided every 8 to 12 hours for 10 days (max $900\,\text{mg/day}$).

  • Indications for Tonsillectomy: Recurrent tonsillitis (>7\,\text{episodes/year}), persistent chronic non-responsive tonsillitis, recurrent peritonsillar abscess, unilateral tonsillar hypertrophy, hemorrhagic tonsillitis, or chronic symptomatic tonsillolithiasis.

  • Tonsillitis Complications:

    • Nonsuppurative: Scarlet fever, acute rheumatic fever, post-streptococcal glomerulonephritis.

    • Suppurative: Peritonsillar abscess (quinsy), parapharyngeal abscess, retropharyngeal abscess.

• Pharyngitis:

  • Acute Pharyngitis:

    • Sudden painful sore throat caused by inflammation of the pharynx (posterior third of tongue, soft palate, tonsils).

    • Etiology: Most commonly viral (adenovirus, influenza, EBV, HSV); bacterial cause is GABHS (strep throat).

    • Clinical Features: Fiery-red pharyngeal membrane and tonsils, swollen lymphoid follicles flecked with white-purple exudate, enlarged tender cervical nodes, fever, malaise, sore throat, and absence of cough.

    • Complications: Sinusitis, otitis media, peritonsillar abscess, mastoiditis, cervical adenitis, bacteremia, pneumonia, meningitis, rheumatic fever, nephritis.

    • Management: Supportive care for viral; Penicillin for bacterial (Clarithromycin or Azithromycin if penicillin-allergic). Analgesics (Acetaminophen). Strict hand hygiene; avoid sharing utensils or food; avoid tobacco smoke.

  • Chronic Pharyngitis:

    • Persistent pharyngeal inflammation common in dusty environments, voice overuse, chronic cough, and habituated alcohol/tobacco use.

    • Types:

      1. Hypertrophic: General mucosal thickening and vascular congestion.

      2. Atrophic: Late stage; membrane becomes thin, whitish, glistening, and wrinkled.

      3. Chronic Granular ("Clergyman's Sore Throat"): Characterized by multiple swollen lymph follicles studded across the pharyngeal wall.

    • Symptoms: Constant throat irritation, fullness, persistent mucus accumulation cleared by coughing, and dysphagia.

    • Medical Management: Nasal decongestants (Ephedrine sulfate, Phenylephrine, Pseudoephedrine); tonsillectomy for refractory adult cases. Avoid environmental pollutants, cold air, alcohol, and tobacco.

Laryngitis & Inflammatory Airway Conditions

• Laryngitis Overview:

  • Inflammation of the laryngeal mucosa and vocal cords leading to edema and tissue congestion.

  • Acute Laryngitis: Lasts less than 3 weeks; typically temporary and self-limiting.

  • Chronic Laryngitis: Persists for longer than 3 weeks.

• Etiology:

  • Infectious Causes: Viral (Rhinovirus [most common], Parainfluenza, RSV, Adenovirus, Measles, Mumps); Bacterial (GABHS, Streptococcus pneumoniae, Corynebacterium diphtheriae, Moraxella catarrhalis, Haemophilus influenzae, Bordetella pertussis, Mycobacterium tuberculosis); Fungal (Histoplasma, Candida in immunocompromised clients).

  • Diphtheria (Corynebacterium diphtheriae): Produces a dense, gray pseudomembrane over the nose/throat that causes fatal airway obstruction and releases tissue-damaging exotoxins targeting the heart and peripheral nervous system.

  • Non-Infectious Causes: Inhaled chemical fumes, gastroesophageal reflux disease (GERD), environmental allergies, chronic vocal abuse/strain (singers, cheerleaders), tobacco smoking, excessive alcohol intake, prolonged use of inhaled corticosteroids, thermal/chemical burns, and endotracheal intubation trauma.

• Clinical Features:

  • Hoarseness (dysphonia) or complete loss of voice (aphonia).

  • Dry, burning, raw throat sensation with a dry paroxysmal cough.

  • Dysphagia, generalized body aches, malaise, and fever.

  • Pediatric cases may present with acute dyspnea.

  • Visualized vocal cords appear dusky red, thickened, and edematous.

• Medical & Nursing Management:

  • Supportive Care: Absolute voice rest, continuous warm steam inhalation, fluid intake ($7\text{ to }9\,\text{glasses}$ of water daily), cough suppressants, cool mist humidifiers, and avoidance of cold environments, smoking, and late-night meals.

  • Definitive Medical Care: For GERD-induced laryngitis, prescribe H2-receptor antagonists (Ranitidine) or Proton Pump Inhibitors (Omeprazole). Systemic corticosteroids used for severe burn/inhalation trauma. Appropriate antimicrobial/antifungal drugs for verified bacterial/fungal infections.

  • Diagnostic Laryngoscopy: Direct visual inspection using indirect mirror or fiberoptic laryngoscopy; biopsy performed if suspicious mucosal lesions are present.

• Laryngotracheal Bronchitis (Viral Croup):

  • Viral infection causing acute inflammation and subglottic edema of the larynx, trachea, and bronchi with impaired vocal cord mobility. Commonly affects young children.

  • Etiology: Parainfluenza virus (most common), Adenovirus, RSV.

  • Clinical Manifestations: Begins with URI symptoms, progressing within 2 days to hoarseness, a characteristic seal-like barking cough, inspiratory stridor, and fever. Symptoms worsen at night.

  • Severity Classification:

    • Mild: Occasional barking cough, no stridor at rest, minimal or no retractions.

    • Moderate: Frequent barking cough, audible stridor at rest, noticeable intercostal/suprasternal retractions.

    • Severe: Continuous barking cough, prominent inspiratory and expiratory stridor, severe retractions, decreased air entry, marked distress, and agitation.

  • Management: Moist steam, outdoor cool air, aggressive oral/IV hydration, dexamethasone (glucocorticoid), and nebulized racemic epinephrine. Hospitalization indicated for severe dehydration, respiratory distress, or impending respiratory failure.

• Spasmodic Croup:

  • Sudden, non-infectious paroxysmal croup condition occurring at night in children aged 1 to 3 years.

  • Characterized by subglottic edema, seal-like barking cough, hoarseness, and stridor without any viral URI prodrome. Managed at home.

• Epiglottitis:

  • Definition: Acute, rapidly progressive, life-threatening inflammation of the epiglottis and surrounding supraglottic tissues. Primarily affects children aged 2 to 7 years.

  • Etiology: Haemophilus influenzae type B (Hib), Streptococcus pneumoniae, Haemophilus parainfluenzae, Staphylococcus aureus, and Beta-hemolytic streptococci.

  • Classic Triad of Symptoms: Drooling, Dysphagia, and Distress.

  • Clinical Manifestations: High fever, tripod sitting position (leaning forward, neck extended, chin thrust out), dyspnea, inspiratory stridor, intercostal accessory muscle retractions, muffled "hot potato" voice, and brassy seal-bark cough.

  • Diagnostics: Lateral neck x-ray displaying a swollen, edematous epiglottis ("thumbprint sign"); leukocytosis; positive blood cultures. Direct laryngeal inspection should ONLY be conducted in a controlled environment (operating room) prepared for immediate emergency intubation.

  • Differential Diagnosis: Anaphylaxis, croup, retropharyngeal abscess, foreign body airway obstruction.

  • Emergency Management:

    1. Immediately secure airway via endotracheal intubation (or emergency cricothyroidotomy if complete obstruction occurs).

    2. Keep child in an upright sitting position; administer humidified supplemental oxygen.

    3. Initiate immediate IV antibiotic therapy: Ceftriaxone, Cefotaxime, or Ampicillin combined with Chloramphenicol.

    4. Evaluate for extubation $24\text{ to }48\,\text{hours}$ post-intubation.

    5. Administer prophylactic oral Rifampin daily for 4 days to all household contacts if unimmunized children reside in the home.