Chapter 27: Acute Lower Respiratory Tract Disorders

Learning Objectives

  • For selected acute respiratory disorders, describe:
      - Pathophysiology
      - Signs and Symptoms
      - Complications
      - Diagnostic Measures
      - Medical Treatment
  • Assist in developing a nursing care plan for patients with acute respiratory disorders.

Acute Bronchitis

Cause and Risk Factors
  • Viral: Caused by cold or flu viruses.
  • Bacterial: Common bacterial offenders include:
      - S.pneumoniaeS. pneumoniae
      - H.influenzaeH. influenzae
  • Noninfectious: Inhalation of toxins.
Signs and Symptoms
  • Cough
  • Sputum production
  • Fatigue
  • Dyspnea on exertion
  • Wheezing or rhonchi
  • Fever
  • Chest pain
  • Symptoms similar to upper respiratory infections (e.g., nasal congestion, runny nose, sore throat).
Medical Diagnosis
  • Diagnosis based on health history and clinical presentation.
Medical Treatment
  • Antitussives: e.g., Dextromethorphan
  • Expectorants: e.g., Guaifenesin
  • Beta-2 Agonists: e.g., Albuterol.
Nursing Care
  • Humidification to help with symptoms.
  • Eliminate environmental triggers.
  • Precautions as necessary.

Influenza

Complications
  • Possible complications include:
      - Bronchitis
      - Viral or bacterial pneumonia
      - Sinus or ear infections.
      - Acute respiratory failure secondary to the flu.
      - Multiple organ dysfunction syndrome (MODS).
      - Cardiac complications: EKG abnormalities, acute myocardial infarction, myocarditis, pericarditis.
      - CNS complications: Encephalitis, aseptic meningitis, encephalopathy, Guillain-Barré syndrome.
Signs and Symptoms
  • Abrupt onset of:
      - High fever (102°F–104°F; 38°C–40°C lasting 3-4 days).
      - Cough and sore throat.
      - Headache.
      - General body aches and pains.
      - Exhaustion and fatigue.
      - Older adults may experience altered mental status without fever.
Medical Diagnosis
  • Rapid influenza diagnostic tests (RIDTs).
  • Rapid molecular assays via nasal/throat/ nasopharyngeal swab.
Medical Treatment
  • Antipyretics: Analgesics (not echinacea).
  • Antivirals to prevent or treat within 48H of symptom onset:
      - Oral Oseltamivir (Tamiflu)
      - Baloxavir (Xofluza)
      - Inhaled Zanamivir (Relenza)
      - Intravenous Peramivir (Rapivab).
  • Yearly Vaccine: Recommended for everyone aged >6 months.
Nursing Care
  • Most susceptible groups:
      - Young children, older adults, pregnant and postpartum women.
      - Extremely obese individuals.
      - People in institutional settings.
      - Individuals with chronic illnesses.
      - Immunosuppressed people, Native Americans, Alaska Natives, healthcare personnel who contact high-risk patients.

Pneumonia

Cause and Risk Factors
  • Inflammation of lung areas such as alveoli and bronchioles.
  • Noninfectious Agents: Irritating fumes (e.g., from cigarettes), dust, chemicals, aspirated foreign matter (liquid/solid).
  • Infectious Agents:
      - Bacteria: S.pneumoniaeS. pneumoniae
      - Fungi: PneumocystisjiroveciiPneumocystis jirovecii
      - Viruses: Influenza, RSV.
      - Health care-associated infection (HAI): Non-intubated patients within 48 hours of admission.
      - Community-acquired infection (CAI): Patients living in the community within the previous 14 days.
      - Ventilator-associated pneumonia (VAP).
  • At-risk groups:
      - Individuals with altered consciousness, immunocompromised states, chronic illnesses, prolonged immobility, impaired swallowing/cough reflex.
Pathophysiology
  • Fluid accumulation in the lungs due to pathogen invasion.
  • Hepatization: Activation leads to capillary dilation, infiltration by neutrophils, RBCs, and fibrin filling the alveoli, making the lung appear red and granular.
  • Eventually, blood flow decreases and the area consolidates through WBC and fibrin infiltration.
  • Resolution: Consolidated materials dissolve, and macrophages remove debris.
Complications
  • Leading cause of death in the U.S. for ages >65.
  • Complications include:
      - Pleurisy
      - Pleural effusion
      - Atelectasis
      - Lung abscess, bacteremia, pneumothorax, meningitis, acute respiratory failure, sepsis/septic shock, empyema.
Signs and Symptoms
  • Abrupt onset including:
      - Fever
      - Chills
      - Cough
      - Side pain
      - Sputum production
      - Hemoptysis
      - Dyspnea
      - Headache
      - Fatigue.
      - In older adults: confusion, delirium.
Medical Diagnosis
  • Sputum culture and Gram stain.
  • Chest radiograph, CBC, blood culture, pneumococcal urinary antigen.
Medical Treatment
  • Increased fluid intake, limited activity or bed rest, antipyretics, analgesics, and oxygen therapy if necessary.
  • Antimicrobials: Necessary based on causative agent.
  • Vaccinations for Pneumococcal Conjugate Vaccine (PCV 15/20/21/23).
Nursing Care
  • Assessment: Listen for crackles/wheeze.
  • Intervention for Acute Pain: Encourage splinting during deep breathing/coughing.
Interventions
  • Airway obstruction: Manage secretions to improve expectoration. Use:
      - Antimicrobials
      - Decongestants
      - Expectorants
      - Antitussives.
  • Positioning: Regular changes, elevate HOB, perform deep breathing and coughing exercises.
Prevention of Aspiration Pneumonia
  • Dysphagia Care: Position upright; semisolids preferred over thin liquids.
  • Enteral Feeding: Maintain HOB at +30° during feedings.
  • Unconscious Patients: Keep elevated HOB.
  • No oral fluids until gag reflex is present.

Pleurisy (Pleuritis)

Description
  • Inflammation of the pleura.
Causes
  • Conditions include:
      - Pneumonia
      - Tuberculosis
      - Chest wall injury
      - Pulmonary infarction
      - Tumors.
Symptoms
  • Characterized by abrupt and severe unilateral pain.
Treatment
  • Address underlying conditions; provide pain relief.
Nursing Care
Pain Management
  • Use of analgesics, splinting the affected side during coughing.
  • Administer anti-inflammatory agents (acetaminophen, NSAIDs), antitussives, antimicrobials as needed.
  • Provide local heat therapy for comfort.
Inadequate Oxygenation Management
  • Encourage turning, deep breaths, coughing, ambulation, and elevating HOB.
  • Monitor for signs of pleural effusion: progressive dyspnea, decreased or absent breath sounds, decreased chest wall movement on affected side; consider thoracentesis as necessary.

Chest Trauma

Causes
  • Nonpenetrating (blunt): Vehicle accidents, falls, blast injuries (e.g., rib fractures, pneumothorax, pulmonary contusion, cardiac contusion).
  • Penetrating: Gunshot or stabbing injuries (e.g., result in pneumothorax or severe vessel tears).
Effects
  • Leads to changes in pressure relationships between air inside and outside the body.
  • May interfere with normal breathing, leading to inflammation, swelling, pain, risk of air entry into the pleural space, increased secretions, hemorrhage, and collection of abnormal fluid in the lungs.
Signs and Symptoms
  • Visible chest trauma signs:
      - Bruising
      - Chest pain
      - Dyspnea
      - Cough
      - Asymmetric chest wall movement
      - Cyanosis.
Medical Treatment
  • Immediate care goals include:
      - Stabilization
      - Prevention of further injury.
  • Use vented dressings and position the patient appropriately (e.g., semi-Fowler position or on the injured side).

Pneumothorax

Description
  • Accumulation of air in the pleural cavity leading to lung collapse.
Causes
  • Chest injury leading to:
      - Holes in the chest wall.
      - Tears in bronchus/bronchioles/alveoli.
      - Spontaneous rupture of air sacs.
Types of Pneumothorax
  • Open Pneumothorax: Mediastinal flutter; allows air movement in and out, causing lung collapse and mediastinal shift.
  • Tension Pneumothorax: Life-threatening condition where trapped air cannot escape, raising pressure and compromising heart blood return.
Signs and Symptoms
  • Air heard/moved through a wound indicates a sucking chest wound.
  • Other symptoms include dyspnea, tachypnea, tachycardia, restlessness, chest pain, anxiety, reduced movement of the affected chest wall, asymmetric motion, diminished breath sounds on affected side, progressive cyanosis.
Medical Treatment
  • Includes needle aspiration, chest tube placement, or surgery to repair tears in lung or bronchus.
Nursing Care
Inadequate Oxygenation Management
  • Recognize signs of respiratory distress efficiently and protect the chest tube.
  • Appropriate positioning: Fowler or semi-Fowler, avoid lying on the affected side.
  • Encourage deep breathing and coughing every 2 hours while awake.
Other Interventions
  • Administer oxygen and monitor for potential complications such as infection:
      - Check for fever, increased heart rate, redness/swelling, foul drainage from insertion site, elevated WBC count.

Hemothorax

Description
  • Blood accumulation between chest wall and lung, often associated with pneumothorax.
Causes
  • May result from lacerated vessels or lung tissue, malignancies, or pulmonary embolism.
Management
  • Treat similarly to pneumothorax; surgical intervention may be necessary to control bleeding.

Rib Fractures

Description
  • Result from blunt trauma, commonly ribs 4-10; usually heals in about 6 weeks.
Signs and Symptoms
  • Pain at the injury site (exacerbated by inspiration), possible bruising or surface markings, swelling, respiratory patterns may include protective chest holding.
Medical Treatment
  • Inpatient care may be required for fractures of >3 ribs:
      - Intercostal nerve blocks for anesthesia
      - Analgesics, mild sedatives
      - Possible surgical stabilization.
Nursing Care
Assessment
  • Watch for signs of pneumothorax.
Goals
  • Improve oxygenation and manage pain adequately.
Interventions
  • Breathing exercises and the use of incentive spirometry while supporting fractured ribs.

Flail Chest

Description
  • Caused typically by multiple rib fractures leading to paradoxical movement of the chest wall.
Signs and Symptoms
  • Dyspnea, cyanosis, tachypnea, and paradoxical chest movement.
Medical Diagnosis
  • History, clinical presentation, chest radiographs, arterial blood gas (ABG) tests.
Medical Treatment
  • May require intubation and mechanical ventilation; surgical stabilization for fractured ribs.
Nursing Care
  • Refer to fractured rib care guidelines.

Pulmonary Embolus

Risk Factors
  • Recent surgery on pelvis or lower limbs, immobility, obesity, estrogen therapy, clotting abnormalities.
Cause
  • An embolus occludes a portion of a pulmonary blood vessel, potentially causing V-P mismatch and hypoxemia.
  • Large vessel obstruction leads to alveoli collapse, reduced cardiac output, and constricted bronchi.
Signs and Symptoms
  • Rapid onset of dyspnea, chest pain, anxiety, diaphoresis, cough with hemoptysis, orthopnea, unilateral leg pain.
Medical Diagnosis
  • Based on history/presentation, imaging (CTPA, ventilation-perfusion scanning), lower extremity ultrasound, ABGs, D-dimer, ECG.
Medical Treatment
  • Anticoagulation Therapy:
      - Low molecular weight heparin (e.g., Enoxaparin).
      - Unfractionated heparin.
      - Direct acting thrombin inhibitors (e.g., Dabigatran).
      - Selective factor Xa inhibitors (e.g., Fondaparinux).
Surgical/Special Treatments
  • Fibrinolytics: Tissue plasminogen activator (t-PA)
  • Oxygen therapy, intubation, mechanical ventilation as needed.
  • Surgical interventions: Embolectomy or vena cava interruption for significant cases.
Nursing Care
Inadequate Oxygenation
  • Elevate HOB and monitor for respiratory distress.
  • Encourage ambulation after starting anticoagulants.
  • Precautions against potential bleeding (monitor aPTT, PT/INR).
Education
  • Teach patients signs of bleeding and prevention methods.

Respiratory Arrest and ARDS

Notes from ARDS Treatment Guidelines
  • Follow current AHA guidelines for respiratory arrest treatment.
  • Understand ARDS pathophysiology and its signs, focusing on progressive respiratory distress, tachypnea, and hypoxemia.
Medical Treatment
  • Intubation and mechanical ventilation with PEEP as required.
  • Ensure sedation and possible neuromuscular blockade; position patients prone as indicated.