Respiratory & Sepsis Comprehensive Study Notes

Disruptions to the Pleural Space

• Normal pleural space = negative intrapleural pressure (slightly below atmospheric)
• Any entry of air, blood, fluid or pus → loss of negative pressure → lung collapse

Pneumothorax Types

• Open (sucking) pneumothorax
– Penetrating chest‐wall wound (GSW, stab, impalement)
– Sucking sound; severe dyspnea
– Air flows freely between lung & atmosphere
• Closed pneumothorax
– Chest wall intact; hole in lung tissue (e.g., barotrauma from high vent pressures)
– Air leaks from lung into pleural space
• Tension pneumothorax
– One-way valve effect → progressive rise in intrathoracic pressure
– Compresses heart/great vessels → ↓venous return, ↓CO, mediastinal shift
– Late sign = tracheal / mediastinal shift
– Emergency management: immediate needle thoracostomy (2nd ICS, mid-clavicular) followed by chest tube

Assessment Findings (Closed PTX)

• Sudden sharp pleuritic pain (affected side)
• ↓/Absent breath sounds & unequal chest rise
• Dyspnea, tachypnea; possible tachycardia
• Trachea usually midline unless tension develops

Complications if Untreated

• Tension pneumothorax → obstructive shock → cardiovascular collapse

Other Pleural Collections

• Hemothorax = blood
• Pleural effusion = serous / transudative / exudative fluid
• Empyema = pus

Pleural Effusion vs Pulmonary Edema

• Effusion: fluid outside lung (between visceral & parietal pleura)
– Treated with thoracentesis or chest tube
• Edema: fluid inside lung (interstitium & alveoli)
– Treat underlying cause, diuretics, PEEP

Chest Tubes

• Purpose = one-way valve to drain air / fluid & restore negative pleural pressure → lung re-expansion
• Indications: pneumothorax, hemothorax, pleural effusion, empyema, post-op thoracic surgery
• Systems use gravity/water seal ± suction (-20 cm H₂O typical dry suction setting)

Chamber Monitoring

• Water-seal chamber
– Intermittent bubbling early in pneumothorax = normal
– New continuous bubbling = air leak → troubleshoot & call provider
– Tidaling (fluctuation with respiration) normal; stops when lung re-expanded or tube obstructed
• Collection chamber
– Note color, amount, consistency
– >200 mL/hr bright-red blood or sudden change → urgent

Red-Flag Situations

• Continuous bubbling, sudden cessation of tidaling, >250 mL bright-red output/hr
• Post-thoracentesis / tube removal → sudden dyspnea & unilateral ↓breath sounds = possible recurrent PTX

Ventilation vs Oxygenation

• Ventilation = physical movement of air (in & out)
• Oxygenation = addition of O₂ to blood (diffusion & Hb binding)

Normal vs Mechanical

• Normal breathing = negative‐pressure ventilation
• Mechanical ventilator = positive‐pressure ventilation (air forced in)

Mechanical Ventilator Settings

• $RR$ (breaths / min) – affects ventilation
• $TV$ (tidal volume, mL) – affects ventilation, set $6–10\,mL·kg^{-1}$ ideal body wt
• $PEEP$ (cm H₂O, min 5) – prevents alveolar collapse, improves oxygenation; high PEEP (up to 30) → risk hypotension/barotrauma
• FiO2 (% O₂, 21–100 %) – directly affects oxygenation • Minute ventilation formula: $V</em>E = RR \times TV$ (e.g., $10\,\text{bpm} \times 450\,mL = 4500\,mL·min^{-1}$)

V/Q Ratio & Mismatch

• Ideal $V/Q = 1$ (ventilation = perfusion)

Low V/Q (<1) – Shunt Physiology (↓Ventilation)

• Causes: COPD, asthma, mucus plug, pneumonia, pulmonary edema, atelectasis
• Body compensates: hypoxic vasoconstriction (shunts blood away)

High V/Q (>1) – Alveolar Dead Space (↓Perfusion)

• Causes: pulmonary embolism, severe hypotension, right HF
• Body compensates: bronchoconstriction to non-perfused alveoli → wheezing in PE

Example numbers: Severe COPD → $0.5/1=0.5$ (low). PE → $1/0.5=2$ (high).

Chronic Obstructive Pulmonary Disease (COPD)

Obstructive vs Restrictive Definition

• Obstructive = ↑ airway resistance, trouble exhaling (COPD, asthma)
• Restrictive = ↓ compliance, trouble inhaling (pulmonary fibrosis, obesity, rib fracture)

Chronic Bronchitis

• Inflammation, hypersecretion of mucus, productive cough ≥3 mo × 2 yrs
• Loss of ciliary function → infection risk ↑

Emphysema

• Elastin destruction → floppy, enlarged alveoli
• ↓Elastic recoil → air trapping, ↑residual volume, barrel chest
• Septal destruction → ↓surface area → V/Q mismatch & hypoxemia
• Etiologies: 20-yr smoking (secondary); Alpha-1 antitrypsin deficiency (primary) – uncontrolled elastase activity

Exacerbation Prevention Teaching

• Vaccines (flu, pneumococcal), avoid sick contacts, mask in crowds, hand hygiene, incentive spirometry

Oxygen Therapy

• Yes – titrate to SpO₂ 88–92 % (avoid both hypoxia & CO₂ retention)

Pulmonary Embolism (PE)

• Most common cause = DVT; other: fat embolus (long-bone fracture), air embolus (iatrogenic), tumor emboli
• Risk factors: immobility/long flight, ortho surgery, pregnancy, smoking+OCP, cancer, hypercoagulable state

Clinical Presentation

• Sudden dyspnea, pleuritic chest pain, tachycardia, ↓SpO₂, wheezing (bronchoconstriction to dead space), feeling of impending doom

Diagnosis & Treatment

• D-dimer, CT angiography, V/Q scan
• Management: O₂, fibrinolytic (alteplase) if massive; anticoagulation if stable; consider embolectomy/IVC filter

Protective Respiratory Mechanisms & Their Loss in COPD

• Cilia, mucus (goblet cells), cough/sneeze reflex
• COPD damages cilia & increases mucus → infectious exacerbations

LTB vs Acute Epiglottitis (Pediatric)

• Stridor = high-pitched inspiratory sound from airway narrowing
• Grunting on expiration = auto-PEEP to maintain alveolar pressure
• Nasal flaring = attempt to ↓airflow resistance during distress

Sepsis

• Definition progression
– SIRS + confirmed/suspected infection = Sepsis
– Sepsis + organ dysfunction = Severe Sepsis
– Severe sepsis + refractory hypotension = Septic Shock

qSOFA Criteria (≥2 → high mortality risk)

• RR ≥22 /min
• Altered mentation (GCS <15)
• SBP ≤100 mmHg

Pathophysiology Highlights

• Dysregulated host response: simultaneous hyper-inflammation & immunosuppression
• Endothelial injury → capillary leak, microthrombi (DIC)-(petici), tissue hypoxia
• Switch to anaerobic metabolism → ↑lactate (>2 mmol·L⁻¹ concerning)
• Hypermetabolism → stress hyperglycemia

Sepsis 1-Hour Bundle (Surviving Sepsis)

1. Measure serum lactate & re-measure if >2

2. Obtain blood cultures before antibiotics

3. Administer broad-spectrum IV antibiotics

4. Rapid crystalloid/“balanced” fluid bolus $30\,mL·kg^{-1}$ if hypotensive or lactate ≥4

5. Vasopressors (norepinephrine) to maintain MAP ≥65 mmHg if hypotension after fluids

Nursing Care Priorities

• Neuro: monitor LOC
• CV: fluids, vasopressors, cap refill, MAP, lactate trend
• Resp: O₂, consider mechanical ventilation
• Renal: I/O, avoid nephrotoxins, monitor creatinine
• Metabolic: control BG (<180 mg·dL⁻¹ with insulin), nutrition

Quick Facts & Formulas

• Minute ventilation: $V<em>E = TV \times RR$ • PEEP minimum: $5\,cm\,H</em>2O$
• Chest tube water seal tidaling stops → either lung re-expanded or tube obstructed/kinked
• Alpha-1 Antitrypsin protects elastin; deficiency → early emphysema
• Erythropoietin produced by kidneys in hypoxia → chronic kidney disease causes chronic anemia
• Diaphragm innervated by phrenic nerve (C3–C5)
• High cervical spine injury or medulla/pons lesion → ventilatory failure → prepare for intubation & mechanical ventilation

Medication Highlights

• Albuterol (short-acting β₂-agonist) – quick bronchodilation; SE: tachycardia, tremor
• Salmeterol/formoterol – long-acting β₂; maintenance
• Inhaled corticosteroids (fluticasone, budesonide) – ↓airway inflammation; rinse mouth
• Prednisone burst – 10-14 days post-COPD exacerbation
• Azithromycin/cefuroxime – empiric ABX for COPD infectious exacerbation
• Voriconazole – systemic antifungal; watch LFTs, photosensitivity
• Ganciclovir – antiviral for CMV; bone-marrow suppression
• Palivizumab – RSV prophylaxis in high-risk infants
• Alteplase – fibrinolytic for massive PE
• Norepinephrine (levophed) – first‐line vasopressor in septic shock
• Naloxone – opiate overdose with pinpoint pupils & bradypnea

Obstructive vs Restrictive Disease Comparison

• Compliance: ↑ in obstructive (overinflated), ↓ in restrictive (stiff)
• Tidal Volume: ↑ obstructive, ↓ restrictive
• Residual Volume & Expiratory Time: ↑ & prolonged in obstructive
• Both may have ↑RR but restrictive tends to shallow breathing

Decreased Compliance Etiologies

• Chest wall: osteoarthritis, rib fracture trauma
• Lung: pneumothorax, pleural effusion
• Alveolar: pulmonary edema, pulmonary fibrosis, loss of surfactant

Final Pearl Questions (Self-Check)

• Condition with adequate ventilation but no perfusion? → Alveolar dead space / high V/Q
• Late sign of tension PTX? → Mediastinal shift
• Why give humidity in LTB/Epiglottitis? → Soothes inflamed mucosa & loosens secretions; work if stridor decreases
• Why lactate rises in sepsis? → Anaerobic metabolism from tissue hypoperfusion

NCLEX-Style Questions with Rationales

1. A nurse is assessing a client with a known pneumothorax. Which assessment finding would indicate a tension pneumothorax?
   A) Sudden sharp pleuritic pain on the affected side
   B) Unilateral decreased breath sounds
   C) Tracheal deviation to the unaffected side
   D) Intermittent bubbling in the chest tube water-seal chamber
   Correct Answer: C
   Rationale: Tracheal deviation and mediastinal shift are late and critical signs of a tension pneumothorax due to the progressive rise in intrathoracic pressure causing compression and shift of mediastinal structures away from the affected lung. Options A and B are general findings for various types of pneumothorax. Option D is a normal finding in the early management of a pneumothorax with a chest tube.

2. A client is admitted with a penetrating chest wound and is exhibiting a sucking sound at the wound site with severe dyspnea. The nurse recognizes these findings as indicative of which type of pneumothorax?
   A) Closed pneumothorax
   B) Tension pneumothorax
   C) Open (sucking) pneumothorax
   D) Spontaneous pneumothorax
   Correct Answer: C
   Rationale: An open (sucking) pneumothorax is characterized by a penetrating chest-wall wound that allows air to flow freely between the lung and the atmosphere, often causing a 'sucking sound' and severe dyspnea.

3. Which of the following interventions is the priority for immediate management of a tension pneumothorax?
   A) Administering a large bolus of intravenous fluids
   B) Preparing for immediate needle thoracostomy
   C) Placing the client in a high Fowler's position
   D) Initiating continuous positive airway pressure (CPAP)
   Correct Answer: B
   Rationale: Immediate needle thoracostomy (2nd ICS, mid-clavicular) is the emergency management for a tension pneumothorax to relieve the trapped air and restore negative pressure, followed by chest tube insertion.

4. A nurse is monitoring a client with a chest tube for a pneumothorax. Which finding in the water-seal chamber would prompt the nurse to immediately troubleshoot for an air leak and notify the provider?
   A) Intermittent bubbling during expiration
   B) Tidaling (fluctuation with respiration)
   C) Continuous vigorous bubbling
   D) Cessation of tidaling after lung re-expansion
   Correct Answer: C
   Rationale: New or continuous bubbling in the water-seal chamber indicates an air leak, which needs immediate assessment and intervention. Intermittent bubbling and tidaling are normal findings. Cessation of tidaling is expected when the lung has re-expanded or if the tube is obstructed.

5. The healthcare provider orders a chest tube removal for a client. Following the procedure, the nurse should closely monitor the client for which priority complication?
   A) Increased appetite
   B) Sudden dyspnea and unilateral decreased breath sounds
   C) Mild pain at the incision site
   D) Normal SpO₂ levels
   Correct Answer: B
   Rationale: Sudden dyspnea and unilateral decreased breath sounds after chest tube removal or thoracentesis are red-flag signs of a possible recurrent pneumothorax, requiring urgent assessment.

6. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. The nurse should titrate oxygen to maintain an SpO₂ within which target range?
   A) 95-100%
   B) 90-94%
   C) 88-92%
   D) 85-89%
   Correct Answer: C
   Rationale: For clients with COPD, oxygen should be titrated to an SpO₂ of 88-92% to avoid both hypoxia and the risk of CO₂ retention, which can worsen respiratory acidosis.

7. A nurse is educating a client with chronic bronchitis. Which statement by the client indicates a need for further teaching about the condition?
   A) "I have inflammation and increased mucus, which causes my productive cough."
   B) "My cilia help remove mucus, so I'm not at high risk for infections."
   C) "I have a productive cough for at least 3 months each year for the past 2 years."
   D) "I need to get my flu and pneumonia vaccines regularly."
   Correct Answer: B
   Rationale: Chronic bronchitis involves loss of ciliary function, which increases the risk of infection. The client's statement that cilia help remove mucus and prevent infection indicates a misunderstanding. The other statements are accurate descriptions of chronic bronchitis or preventive measures.

8. Which of the following is an expected finding in a client with emphysema due to the destruction of lung elastin?
   A) Increased elastic recoil
   B) Decreased residual volume
   C) Barrel chest and air trapping
   D) Decreased airway resistance
   Correct Answer: C
   Rationale: Emphysema is characterized by elastin destruction, leading to decreased elastic recoil, air trapping, increased residual volume, and a barrel chest. It also causes increased airway resistance, not decreased.

9. A nurse is explaining the difference between ventilation and oxygenation. Which statement accurately describes ventilation?
   A) The process of adding O₂ to the blood
   B) The physical movement of air in and out of the lungs
   C) The binding of oxygen to hemoglobin
   D) The diffusion of gases across the alveolar-capillary membrane
   Correct Answer: B
   Rationale: Ventilation is defined as the physical movement of air (in & out). Options A, C, and D relate to oxygenation.

10. A client with a long-bone fracture develops sudden dyspnea, pleuritic chest pain, and tachycardia. The nurse suspects a pulmonary embolism (PE). What is the most common cause of PE?
    A) Air embolus
    B) Tumor emboli
    C) Deep vein thrombosis (DVT)
    D) Amniotic fluid embolus
    Correct Answer: C
    Rationale: The most common cause of pulmonary embolism is a deep vein thrombosis (DVT). While other types of emboli can occur, DVT is the predominant etiology.

11. A nurse is reviewing a client’s arterial blood gases and notes a $V/Q$ ratio of 0.5. This finding indicates which of the following?
    A) High $V/Q$ ratio (Alveolar Dead Space)
    B) Ideal $V/Q$ ratio
    C) Low $V/Q$ ratio (Shunt Physiology)
    D) Pulmonary embolism
    Correct Answer: C
    Rationale: A low $V/Q$ ratio (less than 1) indicates shunt physiology, where perfusion is adequate but ventilation is decreased (e.g., $0.5/1=0.5$). This is commonly seen in conditions like pneumonia or pulmonary edema. High $V/Q$ is greater than 1.

12. Which ventilator setting is primarily responsible for preventing alveolar collapse and improving oxygenation?
    A) Respiratory Rate ($RR$)
    B) Tidal Volume ($TV$)
    C) Positive End-Expiratory Pressure ($PEEP$)
    D) $FiO*2$
    *Correct Answer: C*
    Rationale: $PEEP$ (Positive End-Expiratory Pressure) is a ventilator setting that maintains a positive pressure in the alveoli at the end of expiration, preventing their collapse and thus improving oxygenation. $RR$ and $TV$ primarily affect ventilation.

13. The nurse is caring for an infant admitted with LTB (Croup). Which clinical manifestation is most characteristic of LTB?
    A) Drooling and dysphagia
    B) Barky cough and inspiratory stridor
    C) Sudden onset with high fever
    D) Tripod posture
    Correct Answer: B
    Rationale: LTB (Croup) typically presents with a hallmark barky cough and inspiratory stridor, usually caused by a viral infection and having a gradual onset. Drooling, dysphagia, sudden onset, high fever, and tripod posture are more indicative of Epiglottitis.

14. A client in the intensive care unit is exhibiting signs of severe sepsis. According to the Sepsis 1-Hour Bundle, which action should the nurse prioritize after measuring serum lactate and obtaining blood cultures?
    A) Administering vasopressors
    B) Initiating nutritional support
    C) Administering broad-spectrum IV antibiotics
    D) Preparing for intubation
    Correct Answer: C
    Rationale: According to the Sepsis 1-Hour Bundle, after measuring lactate and obtaining blood cultures, the next priority is to administer broad-spectrum IV antibiotics to combat the infection rapidly. Fluid bolus is also a priority for hypotension/high lactate, and vasopressors if fluids aren't sufficient. Nutritional support and intubation may be necessary but are not the immediate next step in the bundle.

15. A client in septic shock has ongoing hypotension despite receiving a $30 mL·kg⁻¹$ crystalloid fluid bolus. Which medication would the nurse anticipate administering next to maintain a Mean Arterial Pressure (MAP) of greater than or equal to 65 mmHg?
    A) Albuterol
    B) Prednisone
    C) Norepinephrine
    D) Ganciclovir
    Correct Answer: C
    Rationale: Norepinephrine (levophed) is the first-line vasopressor in septic shock to maintain MAP greater than or equal to 65 mmHg if hypotension persists after initial fluid resuscitation. Albuterol is a bronchodilator, prednisone is a corticosteroid, and ganciclovir is an antiviral; none are first-line vasopressors.

16. Which of the following conditions is characterized by increased airway resistance and difficulty with exhalation?
    A) Pulmonary fibrosis
    B) Obesity
    C) COPD
    D) Rib fracture
    Correct Answer: C
    Rationale: Obstructive lung diseases like COPD are characterized by increased airway resistance and difficulty with exhalation. Pulmonary fibrosis, obesity, and rib fracture are causes of restrictive lung disease, which involve decreased compliance and difficulty with inhalation.

17. A client presents with pinpoint pupils and bradypnea after a suspected overdose. Which medication should the nurse anticipate administering?
    A) Alteplase
    B) Naloxone
    C) Azithromycin
    D) Palivizumab
    Correct Answer: B
    Rationale: Naloxone is an opioid antagonist used to reverse the effects of opiate overdose, which typically presents with respiratory depression (bradypnea) and pinpoint pupils. The other medications are used for PE, infection, and RSV prophylaxis, respectively.

18. Which statement correctly identifies a key physiological difference found in obstructive lung disease compared to restrictive lung disease?
    A) Compliance is decreased in obstructive disease.
    B) Tidal Volume is decreased in obstructive disease.
    C) Residual Volume and expiratory time are increased in obstructive disease.
    D) Patients with obstructive disease typically have shallow breathing.
    Correct Answer: C
    Rationale: In obstructive lung disease, there is air trapping, leading to increased residual volume and prolonged expiratory time due to difficulty exhaling. Compliance is increased (overinflated), not decreased. Tidal volume can be increased or normal, not necessarily decreased. Shallow breathing is more characteristic of restrictive lung disease.

19. A nurse is explaining the concept of negative-pressure ventilation. Which of the following is an example of normal, physiological negative-pressure ventilation?
    A) Mechanical ventilator with $PEEP$
    B) BiPAP machine
    C) Spontaneous breathing
    D) CPAP machine
    Correct Answer: C
    Rationale: Normal breathing is a process of negative-pressure ventilation, where the diaphragm contracts, creating negative pressure in the pleural space, which draws air into the lungs. Mechanical ventilators and CPAP/BiPAP machines use positive-pressure ventilation.

20. A client with severe COPD has a $V/Q$ ratio calculated at 0.5. The nurse understands that the body attempts to compensate for this low $V/Q$ mismatch through which mechanism?
    A) Bronchoconstriction to non-perfused alveoli
    B) Hypoxic vasoconstriction
    C) Increased tidal volume
    D) Decreased respiratory rate
    Correct Answer: B
    Rationale: In a low $V/Q$ ratio (low ventilation relative to perfusion), the body compensates through hypoxic vasoconstriction, shunting blood away from poorly ventilated alveoli to better-ventilated areas. Bronchoconstriction compensates for high $V/Q$ (low perfusion). Increased tidal volume and decreased respiratory rate are not direct compensatory mechanisms for $V/Q$ mismatch in this context.

21. Which bodily organ is responsible for producing erythropoietin, and how does its dysfunction lead to chronic anemia?
    A) Liver; impaired iron storage
    B) Lungs; decreased oxygen absorption
    C) Kidneys; inability to stimulate red blood cell production
    D) Spleen; increased red blood cell destruction
    Correct Answer: C
    Rationale: Erythropoietin is primarily produced by the kidneys in response to hypoxia. Chronic kidney disease impairs this production, leading to a decreased stimulation of red blood cell production, thus causing chronic anemia.

22. The phrenic nerve is critical for ventilation because it innervates which structure?
    A) Intercostal muscles
    B) Larynx
    C) Alveoli
    D) Diaphragm
    Correct Answer: D
    *Rationale: The diaphragm is the primary muscle of respiration and