Adult Respiratory Disorders

Adult Respiratory Disorders: Comprehensive Study Notes

Objectives for Studying Adult Respiratory Disorders

• Neck and Lung Assessment: Understand and identify all components involved in a thorough neck and lung assessment.

• Chronic Bronchitis and Emphysema: Compare the clinical manifestations and medical management strategies for patients experiencing chronic bronchitis and/or emphysema.

• COPD Complications: Identify the specific signs and symptoms indicative of complications related to Chronic Obstructive Pulmonary Disease (COPD).

• Ineffective Airway Clearance: Prioritize nursing interventions for patients suffering from ineffective airway clearance due to excessive secretions or obstruction.

• Impaired Gas Exchange: Prioritize nursing interventions for patients with impaired gas exchange resulting from airway inflammation.

• Decreased Intake: Identify nursing interventions for patients experiencing decreased oral intake due to difficulty breathing.

• Fatigue: Identify nursing interventions for patients struggling with fatigue related to accomplishing Activities of Daily Living (ADLs).

• Anxiety: Identify nursing interventions for patients experiencing anxiety triggered by difficulty breathing.

Components of the Head & Lung Assessment

Respiratory System Anatomy

• Upper Airway:

  • Paranasal sinuses

  • Nasal cavity

  • Nasopharynx

  • Soft palate

  • Epiglottis (wafer-thin structure seen on lateral airway X-ray)

  • Larynx and vocal folds

  • Pharynx (including Hypopharynx)

  • Mouth

• Lower Respiratory Tract:

  • Trachea

  • Bronchi (Right and Left primary bronchus)

  • Bronchioles

  • Alveoli (air sacs)

  • Lungs (Right lung: superior, middle, inferior lobes; Left lung: superior, inferior lobes, cardiac notch)

  • Mediastinum (central compartment of the thoracic cavity)

  • Diaphragm (major muscle of respiration)

  • Pleural membranes (surrounding the lungs)

  • Venule (associated with alveolus for gas exchange)

Clinical Indicators of Hypoxia

• Pallor or cyanosis (blue discoloration of skin/mucous membranes)

• Restlessness

• Apprehension (anxiety, uneasiness)

• Confusion

• Dizziness

• Fatigue

• Decreased Level of Consciousness (LOC)

• Tachycardia (elevated heart rate)

• Tachypnea (rapid breathing)

• Changes in blood pressure (can be elevated or decreased depending on severity/chronicity)

Thorax Inspection

• Color: Observe for pallor, cyanosis, or normal skin tone.

• Shape or Contour: Note any deformities such as:

  • Barrel-chest: A rounded or bulging chest, often associated with chronic lung conditions.

• Muscle Development: Assess for any asymmetrical muscle development or wasting.

Breathing Patterns

• Chest Wall Expansion: Observe for symmetry and depth of chest wall movement during respiration.

• Biot's Respirations: Irregular breathing pattern characterized by groups of regular deep inspirations followed by periods of apnea; often associated with head injury.

• Cheyne Stokes: Rhythmic waxing and waning of respiration from very deep to very shallow, with periods of apnea; often related to decreased blood flow to the brainstem.

• Kussmaul Respirations: Deep, labored breathing pattern associated with severe metabolic acidosis, particularly diabetic ketoacidosis.

• Accessory Muscles (Retractions): Use of non-diaphragmatic and intercostal muscles for breathing, indicating increased work of breathing; retractions are visible indentations of the skin between ribs or above the clavicles.

• Agonal Breathing: Gasps and short, labored breaths; a sign of severe cerebral ischemia or anoxia, often occurring just before death.

Normal Breath Sounds

• Bronchial Sounds: Loud, high-pitched, tubular sounds heard over the trachea; expiration is longer than inspiration.

• Bronchovesicular Sounds: Moderate pitch and intensity, heard over major bronchi; inspiration and expiration are equal in length and sound.

• Vesicular Breath Sounds: Soft, low-pitched, breezy sounds heard over peripheral lung fields; inspiration is longer than expiration.

Abnormal Breath Sounds

• Rales (Crackles): Short, discrete, bubbling, or popping sounds typically heard on inspiration.

  • Coarse Rales: Louder, lower-pitched, fewer in number, indicating larger airway secretions.

  • Fine Rales: Softer, higher-pitched, more numerous, indicating fluid in smaller airways or alveoli.

• Wheezes: Continuous, high-pitched, musical sounds heard predominantly on expiration (but can be on inspiration), caused by narrowed airways.

• Stridor: High-pitched, harsh, inspiratory sound caused by obstruction of the upper airway (larynx or trachea), a medical emergency.

• Pleural Friction Rub: Creaking or grating sound, like walking on fresh snow, caused by inflamed pleural surfaces rubbing together.

• Diminished Breath Sounds: Softer than normal, indicating decreased air movement, possibly due to obstruction, emphysema, or shallow breathing.

• Absent Breath Sounds: No air movement detected, indicating complete obstruction, pneumothorax, or surgical removal of a lung.

Respiratory Conditions

Atelectasis

• Definition: Collapse of alveoli, leading to reduced gas exchange.

• Prevalence: Most common in postsurgical patients who do not cough and deep breathe effectively.

• Signs/Symptoms (S/S):

  • Increased work of breathing

  • Hypoxemia (low oxygen in blood)

  • Diminished breath sounds over affected area

  • Increasing dyspnea (shortness of breath) when supine (lying flat)

• Nursing Care Focus: Prevention

  • Goals:

    • Reverse, prevent, or modify underlying causes.

    • Educate patients about the underlying cause, diagnostic process, and treatment plan.

    • Promote patient comfort and coping ability.

  • Interventions:

    • Pulmonary toileting (methods to clear airways)

    • Incentive Spirometry (IS) $10$ times every hour (X$10$ every hour)

    • Turn, Cough, Deep Breathe (TCDB)

    • Elevate Head of Bed (↑ HOB)

    • Suction as needed (PRN)

    • Early ambulation

Pneumonia

• Definition: An infection that occurs when a pathogen enters and multiplies in the lungs.

• Signs/Symptoms (S/S):

  • Fever

  • Shaking chills

  • Chest pain (often pleuritic)

  • Dyspnea

  • Productive cough (with sputum)

  • Crackles/wheezes on auscultation

• Diagnostic Tests:

  • Blood tests (e.g., Complete Blood Count to check White Blood Cell count)

  • Chest X-ray

  • Sputum culture (to identify pathogen)

  • Pulse oximetry (to assess oxygen saturation)

• Nursing Care & Medical Management:

  • Bacterial Pneumonia: Administration of antibiotics.

  • Viral Pneumonia: Supportive care including rest and fluids.

  • Medications: Expectorants (to loosen secretions), bronchodilators (to open airways), analgesics/antipyretics (for pain and fever).

  • Supportive Measures: Supplemental O$_2$ as needed, TCDB, Incentive Spirometry (IS).

Pulmonary Embolism

• Mentioned as a distinct respiratory disorder requiring identification in assessment (detailed S/S not provided in this section but implied). Pulmonary embolism refers to a blockage of an artery in the lungs by a substance that has travelled from elsewhere in the body through the bloodstream (e.g., blood clot).

Chronic Obstructive Pulmonary Disease (COPD)

Overview and Statistics

• Definition: COPD is a serious lung disease that, over time, makes it hard to breathe.

• Prevalence:

  • Currently the $4^{th}$ leading cause of death in the U.S., accounting for nearly $160,000$ deaths per year.

  • More than $16$ million people have been diagnosed with COPD, with millions more estimated to have it but remain undiagnosed.

  • It is a leading cause of disability, affecting an estimated $1$ in $5$ adults aged $45$ and over.

• Pathophysiology: Less air flows in and out of the airways due to one or more of the following:

  • The airways and air sacs lose their elastic quality, preventing proper recoil and air expulsion.

  • The walls between many of the air sacs are destroyed, leading to larger, less efficient air spaces (emphysema).

  • The airway walls become thick, and airways are narrowed by inflammation.

  • The airways produce more mucus than usual, which can further clog them.

• Impact on Daily Life: Left untreated, people with COPD gradually lose their stamina and ability to perform daily activities.

Causes and Risk Factors

• Smoking:

  • Responsible for roughly $8$ out of $10$ COPD deaths and is the number one cause of COPD.

  • $75\%$ of COPD cases occur in people with a history of smoking.

  • Roughly one-half of these cases are current smokers (38\%$), and one-half are former smokers (37\%$).

  • Notably, as many as $1$ out of $4$ people (25\%$) who have COPD have never smoked.

• Long-Term Exposure to Lung Irritants:

  • Long-term exposure to second-hand smoke.

  • Exposure to other lung irritants such as certain chemicals, dusts, or fumes from the environment or workplace.

• Genetic Condition (Alpha-1$Antitrypsin (AAT) Deficiency):</strong></p><ul><li><p>As many as$100,000 Americans have AAT deficiency.

• Individuals with AAT deficiency can develop COPD even if they have never smoked or had long-term exposure to harmful pollutants.

Two Main Conditions within COPD

• Chronic Bronchitis:

  • Characterized by inflammation of the bronchi and excessive mucus production in the airways.

  • Often caused by smoke and other environmental pollutants.

  • Shortness of breath (SOB) may significantly affect a person's ability to eat.

• Emphysema:

  • Involves the destruction of the walls of the alveoli, leading to distended (enlarged) air sacs.

  • This destruction decreases the total surface area available for gas exchange, impairing oxygen uptake and carbon dioxide removal.

Common Signs & Symptoms of COPD

• Shortness of breath (dyspnea), which typically worsens during physical activity.

• Constant coughing, often productive of mucus.

• Use of accessory muscles when breathing, indicating increased respiratory effort.

• General malaise (a general feeling of discomfort, illness, or uneasiness).

• Hyperventilation of the lungs leading to air trapping.

• Flattened diaphragm, visible on chest X-ray, due to hyperinflation.

• Excess mucus production.

• Wheezing sounds during breathing.

• Profound fatigue.

• Weight loss and muscle wasting.

• Depression, often related to chronic illness and limitations.

Diagnosing COPD

• Diagnosis is based on a comprehensive evaluation including:

  • Signs and symptoms reported by the patient.

  • Personal and medical history (especially smoking and exposure history).

  • Physical examinations.

  • Lung function tests, such as spirometry, which measures how much air a person can inhale and exhale, and how quickly air can be exhaled.

Potential Complications of COPD

• Respiratory Infections (e.g., Pneumonia):

  • High mucus volume in the lungs increases patient risk for developing pneumonia.

  • Signs and symptoms to report promptly to a physician:

    • Fever (acute, high fever; in elderly, low-grade fever may be significant).

    • Increased cough and changes in sputum characteristics.

    • Pleuritic chest pain (sharp, stabbing pain during breathing).

    • Increased difficulty breathing.

    • Increased White Blood Cell (WBC) count.

    • Hypoxia (low oxygen in tissues) and hypoxemia (low oxygen in blood).

    • Respiratory insufficiency, leading to activity intolerance.

  • Prevention Strategies:

    • Avoid smoking and other inhaled irritants.

    • Receive annual vaccinations: Pneumococcal vaccine, annual flu vaccine, COVID booster.

    • Avoid large crowds of people or gatherings during peak infection seasons.

  • Medications for Management:

    • Metered Dose Inhalers (MDIs) to open airways (bronchodilators).

    • Corticosteroid inhalers to reduce inflammation.

    • Antitussive agents (cough suppressants) should be avoided with COPD if cough is productive, as it can hinder secretion clearance.

    • Bronchodilators (e.g., short-acting and long-acting).

    • Antibiotics to treat bacterial infections.

• Heart Failure (Cor Pulmonale - Right-Sided Heart Failure):

  • Cor pulmonale is an enlargement of the right side of the heart due to high blood pressure in the lung arteries (pulmonary hypertension), often caused by chronic lung disease.

  • Signs/Symptoms:

    • Hypoxia and hypoxemia.

    • Increasing dyspnea.

    • Fatigue.

    • Enlarged and tender liver (hepatomegaly).

    • Warm, cyanotic hands and feet, with bounding pulses.

    • Cyanotic lips.

    • Pulmonary hypertension (high blood pressure in the pulmonary arteries).

    • Distended neck veins (jugular venous distention).

    • Right ventricular enlargement (hypertrophy) due to increased workload.

    • Visible pulsations below the sternum.

    • Gastrointestinal (GI) disturbances, such as nausea or anorexia.

    • Dependent edema (swelling in the lower extremities, e.g., ankles, feet).

    • Metabolic and respiratory acidosis.

Goals for Patients with COPD

1. Reduce Symptoms: Aim to decrease the severity of symptoms, increase exercise tolerance, and improve the patient's overall health status.

2. Reduce Risk: Minimize the risk for exacerbations (flare-ups), slow disease progression, and reduce mortality.

3. Prevention of Respiratory Infections:

   • Ensure influenza vaccine administration annually.

   • Ensure pneumococcal vaccine administration (as per guidelines).

   • Advise patients to avoid crowds and sick individuals.

   • Promote smoking cessation as a primary intervention.

   • Recommend using a wet cloth for dusting to minimize airborne irritants.

4. Treatment of Respiratory Infections:

   • Administer antibiotics as prescribed for bacterial infections.

   • Utilize mucolytics to thin secretions and help with clearance.

   • Carefully consider antitussives; generally avoided if cough is productive.

5. Reinforce Oxygen Therapy Safety: Educate patients and caregivers on the safe and proper use of supplemental oxygen, including fire safety and proper flow rates.

Nursing Interventions for COPD

1. Pulmonary Rehabilitation:

   • Involves a comprehensive program of education, exercise training, nutrition counseling, and psychological support.

   • Aims to prevent general and pulmonary muscle de-conditioning, improving strength and endurance.

2. Breathing Techniques:

   • Diaphragmatic or Abdominal Breathing: Focuses on using the diaphragm more effectively for deeper breaths.

   • Pursed-Lip Breathing: Helps to slow down exhalation, keep airways open longer, and expel more trapped air.

3. Positioning:

   • Encourage the patient to sit upright in a chair for at least 1$hour, two to three times daily, to promote lung expansion and optimize breathing mechanics.</p></li></ul></li><li><p><strong>Medications:</strong></p><ul><li><p>Administer medications that open airways (bronchodilators) and liquefy secretions (mucolytics) as prescribed.</p></li></ul></li><li><p><strong>Monitor Respiratory Status:</strong></p><ul><li><p>Closely monitor for any worsening respiratory status, as it may indicate the development of a complication (e.g., pneumonia or an exacerbation).</p></li></ul></li></ol><h5 id="c2edf825-8e2c-4023-b9f1-98ed1f25ab31" data-toc-id="c2edf825-8e2c-4023-b9f1-98ed1f25ab31" collapsed="false" seolevelmigrated="true">Other Important Interventions for Patients with COPD</h5><ul><li><p><strong>Quit Smoking:</strong> Absolute cessation of smoking is critical for slowing disease progression.</p></li><li><p><strong>Avoid Pollutants:</strong> Minimize exposure to environmental pollutants, irritants, and allergens.</p></li><li><p><strong>Regular Provider Visits:</strong> Encourage consistent follow-up appointments with healthcare providers and adherence to prescribed medications.</p></li><li><p><strong>Stay Current with Vaccinations:</strong> Emphasize the importance of timely vaccinations to prevent respiratory infections.</p></li><li><p><strong>Seek Support:</strong> Encourage patients to get support from family, friends, and support groups to cope with the challenges of COPD.</p></li></ul><h5 id="c43df21a-36c3-4489-81c1-3b46467711a0" data-toc-id="c43df21a-36c3-4489-81c1-3b46467711a0" collapsed="false" seolevelmigrated="true">Supplemental Oxygen for Patients with COPD Guidelines</h5><ul><li><p><strong>Initiation:</strong> Begin supplemental oxygen if the patient exhibits signs/symptoms of respiratory distress <strong>and</strong> their SpO$2$(oxygen saturation) is less than$88\%$. (Note: A general target for SpO$2$in acute distress is often$<90\%$, but for COPD patients, a slightly lower range is typically aimed for to avoid suppressing the hypoxic drive).</p></li><li><p><strong>Target Saturation:</strong> Adjust oxygen flow to achieve an SpO$_2$between$88\% - 92\%$for most COPD patients.</p></li><li><p><strong>Communication:</strong> Notify the healthcare provider (HP) about the patient's condition and oxygen therapy initiation/adjustment.</p></li></ul><h5 id="e34f8a29-ffe5-489e-b5ca-46a3742dab5d" data-toc-id="e34f8a29-ffe5-489e-b5ca-46a3742dab5d" collapsed="false" seolevelmigrated="true">Breathing Techniques Explained</h5><ul><li><p><strong>Diaphragmatic or Abdominal Breathing:</strong></p><ul><li><p><strong>Position:</strong> Lie on your back with knees bent.</p></li><li><p><strong>Resistance:</strong> Place your hands or a book on your abdomen to create gentle resistance.</p></li><li><p><strong>Breathing Action:</strong> Begin breathing from your abdomen while keeping your chest still. You can tell if you are breathing correctly if your hands or the book rises and falls accordingly with each breath.</p></li></ul></li><li><p><strong>Pursed-Lip Breathing:</strong></p><ul><li><p><strong>Inhale:</strong> Close mouth and breathe in slowly through the nose.</p></li><li><p><strong>Exhale Preparation:</strong> Purse lips as if to whistle.</p></li><li><p><strong>Exhale Action:</strong> Breathe out slowly through the mouth, without puffing the cheeks. The exhalation time should be at least twice the amount of time it took to breathe in (e.g.,$2$seconds for inhale,$4$seconds for exhale).</p></li><li><p><strong>Completion:</strong> Use abdominal muscles to squeeze out every bit of air.</p></li><li><p><strong>Application:</strong> Remember to use pursed-lip breathing during any physical activity. Always inhale before beginning the activity and exhale while performing the activity. <strong>Never hold your breath.</strong></p></li></ul></li></ul><h4 id="fafaa8f4-5d89-47f2-ad98-5c3adf33ce21" data-toc-id="fafaa8f4-5d89-47f2-ad98-5c3adf33ce21" collapsed="false" seolevelmigrated="true">Nursing Interventions for Specific COPD-Related Problems</h4><h5 id="64a9ab24-adcf-4423-a9f4-e61ba443ea2a" data-toc-id="64a9ab24-adcf-4423-a9f4-e61ba443ea2a" collapsed="false" seolevelmigrated="true">Nursing Interventions for Impaired Gas Exchange</h5><ul><li><p>Monitor Arterial Blood Gas (ABG) values and pulse oximetry as ordered to assess oxygenation and ventilation status.</p></li><li><p>Have the patient rate their degree of dyspnea on a scale of$0-10$$ to quantify symptom severity.

   • Assess lung sounds, respiratory rate and effort, and use of accessory muscles periodically.

   • Observe skin and mucous membranes for cyanosis, indicating poor oxygenation.

   • Monitor for confusion or changes in mental status, which can be early signs of hypoxia or hypercapnia.

   • Elevate Head of Bed (↑ HOB) to Fowler or semi-Fowler position to facilitate lung expansion.

   • Position the patient with the