Chapter 24

CARE OF PATIENTS WITH NONINFECTIOUS LOWER RESPIRATORY PROBLEMS

ASTHMA

• Definition: Chronic disorder affecting the airways characterized by
    - Clinical Manifestations:
      - Mucosal edema
      - Bronchoconstriction
      - Excessive mucous production
    - Obstruction Mechanisms:
      - Inflammation
      - Airway hyperresponsiveness

• Affected Areas: Primarily impacts the airways, NOT the alveoli.

ASSESSMENT OF ASTHMA

• Adapted from Global Initiative for Asthma (GINA) 2018.

• Severity Classification:
    - Mild Intermittent: Symptoms occur less than twice a week.
    - Mild Persistent: Symptoms arise more than twice a week but not daily.
    - Moderate Persistent: Daily symptoms with exacerbations twice a week.
    - Severe Persistent: Continual symptoms with frequent exacerbations limiting physical activity and quality of life.

ASSESSMENT OF ASTHMA (2)

• Patient History:
    - Onset and duration of symptoms
    - Precipitating factors (stress, exercise, irritant exposure)
    - Changes in medication regimen
    - Smoking history
    - Medications for relief
    - Other medications taken
    - Self-care methods for relief

• Physical Symptoms:
    - Dyspnea
    - Chest tightness
    - Anxiety or stress
    - Coughing
    - Wheezing
    - Mucous production
    - Use of accessory muscles
    - Prolonged exhalation
    - Poor oxygen saturation
    - Barrel chest: Appearance indicator of chronic respiratory conditions.

ASTHMA: LABORATORY ANALYSIS

• Arterial Blood Gases (ABGs):
    - Hypoxemia: Decreased $PaO_2$
    - Hypocarbia: Decreased $PaCO_2$ (early in the attack)
    - Hypercarbia: Increased $PaCO_2$ (later in the attack)

• Sputum Cultures:
    - Bacteria can indicate infection
    - Allergic asthma may show:
      - Elevated serum eosinophil counts
      - Elevated immunoglobulin (IgE) levels

ASTHMA: DIAGNOSTICS

• Pulmonary Function Tests (PFTs): Most accurate for diagnosing asthma and its severity.
    - Forced Vital Capacity (FVC): Volume of air exhaled from full inhalation to full exhalation.
    - Forced Expiratory Volume in the First Second (FEV1): Volume of air blown out hard and fast during the first second of exhalation after full inhalation.
    - Peak Expiratory Flow: Fastest airflow rate during exhalation.
    - A decrease in FEV1 by 15% to 20% below expected values is common in asthma.
    - An increase of 12% following bronchodilator administration is diagnostic for asthma.
    - Chest X-ray: Used to observe structural changes over time.

PULMONARY FUNCTION TESTS

Test Results Interpretation:

• PEAK EXPIRATORY FLOW METER:
    - Green Zone: Well-Controlled
    - Yellow Zone: Poorly-Controlled
    - Red Zone: Severe

ASTHMA: DRUG THERAPIES

• Drug Classifications:
    - Control Therapy Drugs: Used for long-term management.
    - Reliever Drugs (Rescue): Provide quick relief.

• Bronchodilators:
    - Types:
      - Short-acting
      - Long-acting

• Inhaler Types:
    - Metered Dose Inhaler (MDI)
    - Dry Powder Inhaler (DPI)
    - Soft Mist Inhaler (SMI)

STATUS ASTHMATICUS

• Definition: Severe, life-threatening acute episode of airway obstruction.

• Characteristics:
    - Intensifies once it begins, often unresponsive to standard therapy.
    - Symptoms include labored breathing and wheezing.

• Risks:
    - Delayed treatment can lead to pneumothorax, cardiac or respiratory arrest.

• Treatment Protocol:
    - IV fluids
    - Potent systemic bronchodilator
    - Steroids
    - Epinephrine
    - Oxygen therapy
    - Prepare for emergency intubation if sudden absence of wheezing and low oxygen saturation occurs.

KNOWLEDGE CHECK (1)

• Assessment Indicators of Declining Respiratory Status: (Select all that apply)
    - A. SaO2 95%
    - B. Wheezing
    - C. Retraction of sternal muscles
    - D. Pink mucous membranes
    - E. Tachycardia

KNOWLEDGE CHECK (2)

• Medication Class to Administer: For a client with an SaO2 of 91% and abnormal respiratory effort, the expected medication is:
    - A. Antibiotic
    - B. Beta‑blocker
    - C. Antiviral
    - D. Beta2 agonist

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

• Definition: Collection of lower airway disorders including emphysema and chronic bronchitis.
    - Impact on Function: Interferes with airflow and gas exchange, typically affects middle-aged to older adults.
    - Symptoms:
      - Characterized by bronchospasm and dyspnea that increase in severity over time, potentially leading to respiratory failure.
      - Smoking is a significant cause of COPD.

COPD EXPECTED FINDINGS

• Symptoms:
    - Chronic dyspnea, particularly during acute exacerbations (respiratory rate may reach 40-50/min)
    - Dyspnea during exertion
    - Hypoxemia
    - Presence of crackles and wheezes
    - Rapid and shallow respirations
    - Hypercarbia
    - Right-sided heart failure signs
      - Dependent edema
      - Clubbing of fingers and toes
      - Pallor and cyanosis of nail beds and mucous membranes

EMPHYSEMA VS CHRONIC BRONCHITIS

Emphysema:

• Identification: "Pink Puffer"

• Characteristics:
    - Loss of lung elasticity leading to hyperinflation.
    - Symptoms include dyspnea and need for increased respiratory rate.
    - Air trapping results in enlarged alveoli and collapse of small airways.

Chronic Bronchitis:

• Identification: "Blue Bloater"

• Characteristics:
    - Defined by inflammation of bronchi and bronchioles due to chronic irritant exposure.
    - Characterized by excessive mucus production affecting only airways.

COPD ASSESSMENT

• Areas to Assess:
    - History: Focus on risk factors like smoking, breathing problems, activity limitations, and weight.
    - Physical examination: General appearance and respiratory changes, including lung auscultation.
    - Psychosocial: Impact on daily life.

COPD: LABS/DIAGNOSTICS

• Diagnostic Tools:
    - Hematocrit Levels: Increased due to low oxygenation.
    - Sputum Cultures and WBC Counts: Help diagnose acute respiratory infections.
    - Arterial Blood Gases (ABGs):
      - Hypoxemia indicates decreased $PaO_2$ (less than 80 mm Hg).
      - Hypercarbia indicates increased $PaCO_2$ (greater than 45 mm Hg).
    - Bloodwork: CBC, CMP, and Pulmonary Function Tests

COPD: NURSING INTERVENTIONS

• Priority: Airway management

• Goals:
    - Promote gas exchange
    - Prevent weight loss
    - Minimize anxiety

• Therapeutic Methods:
    - Oxygen therapy
    - Breathing techniques:
      - Diaphragmatic (abdominal) breathing
      - Purse-lipped breathing
    - Positive Expiratory Pressure (PEP) Device

COPD: SURGICAL MANAGEMENT

• Lung Volume Reduction Surgery (LVRS):
    - Focus on removing hyperinflated lung tissue.
    - Goals:
      - Increase expiratory volume
      - Decrease lung capacity and residual volume

COPD: CLIENT EDUCATION

• Recommendations:
    - Consume high-calorie foods to support energy needs.
    - Rest as required.
    - Maintain hand hygiene to prevent infections.
    - Adhere strictly to prescribed medication regimens (inhalers, oral meds).
    - Smoking cessation if needed.
    - Obtain vaccinations (influenza, pneumonia).
    - Use oxygen as prescribed; inform caregivers about the risks of smoking near oxygen.
    - Report unusual findings to healthcare provider.
    - Ensure adequate fluid intake (approximately 2 L or 68 oz daily) unless otherwise advised.

LUNG CANCER

• Overview: Leading cause of cancer-related deaths with poor long-term prognosis due to late diagnosis.

• Types:
    - Bronchogenic carcinomas:
      - Small cell lung cancer
      - Non-small cell lung cancer

• Risk Factors:
    - Repeated exposure to inhaled carcinogens
    - Air pollution
    - Radiation exposure

LUNG CANCER: ASSESSMENT

• Patient History:
    - Consider smoking and other risk factors (workplace, residence).

• Physical Examination: Look for symptoms such as:
    - Hoarseness
    - Coughing
    - Sputum production
    - Hemoptysis
    - Shortness of breath
    - Changes in endurance
    - Chest pain

• Labs/Diagnostics:
    - Biopsy
    - Examination of pleural effusion fluid

LUNG CANCER: NONSURGICAL TREATMENT

• Treatment Modalities:
    - Chemotherapy (including targeted therapy)
    - Radiation therapy
    - Photodynamic therapy

LUNG CANCER: SURGICAL MANAGEMENT

• Options:
    - Lobectomy
    - Pneumonectomy
    - Segmentectomy
    - Wedge resection
    - Median sternotomy
    - Surgical approaches:
      - Posterolateral incision
      - Anterolateral incision

LUNG CANCER: POSTOPERATIVE CARE

• Post-operative management includes:
    - Monitoring: Patient will have a chest tube to drain accumulated air and blood in pleural space, facilitating lung re-expansion.
    - Ensure dressing around the site is dry and intact.
    - Listen for breath sounds.
    - Promote coughing and deep breathing exercises.
    - Manage pain effectively.

LUNG CANCER: PALLIATIVE CARE

• Focus: Managing symptoms and improving quality of life through:
    - Oxygen therapy
    - Radiation therapy
    - Thoracentesis
    - Strategies for dyspnea management
    - Pain management