Management of Patients With Chest and Lower Respiratory Tract Disorders

Atelectasis Collapse or airless condition of alveoli caused by hypoventilation, obstruction to airways, or compression Causes: bronchial obstruction by secretions due to impaired cough mechanism or conditions that restrict normal lung expansion on inspiration Postoperative patients at high risk Symptoms: insidious, include cough, sputum production, low-grade fever Respiratory distress, anxiety, symptoms of hypoxia occur if large areas of lung are affected

Nursing Management Prevention Frequent turning, early mobilization Strategies to improve ventilation: deep breathing exercises at least every 2 hours, incentive spirometer Strategies to remove secretions: coughing exercises, suctioning, aerosol therapy, chest physiotherapy

Nursing Management (cont’d) Treatment Strategies to improve ventilation, remove secretions Treatments: may include PEEP (positive end-expiratory pressure), IPPB (intermittent positive-pressure breathing) Bronchoscopy may be used to remove obstruction

Respiratory Infections Acute tracheobronchitis Pneumonia Community-acquired pneumonia Hospital-acquired pneumonia Pneumonia in immunocompromised host Aspiration pneumonia

Risk Factors Cancer, smoking, COPD (produce mucus, or obstruct bronchus Immunocompromised pt Prolonged immobility and shallow breathing Depressed cough reflex, aspiration of foreign material

Alcoholism GA, sedative Advance age Respiratory therapy with improperly cleaned equipment Transmission of organisms from staff of health care.

Clinical Manifestation Sudden onset of chills, rapid raising fever (38.5 – 40.5o) Pleuritic chest pain increase with deep breathing and coughing Tachypnea ( 25 – 45b\m) Rapid bounding pulse In sever cases cheeks flushed and the lips with nail beds become cyanosed.

Orthopnea Decrease appetite, fatigue Purulent sputum Crackles, increased tactile fermitus, dullness on percussion, bronchial breathing sounds, egophony and whispered pectoriloquy.

Diagnostic Tests Chest x-ray Sputum examination

Medical Treatment of Pneumonia Supportive treatment includes fluids, oxygen for hypoxia, antipyretics, antitussives, decongestants, antihistamines Administration of antibiotic therapy determined by gram-stain results If etiologic agent is not identified, utilize empiric antibiotic therapy Antibiotics not indicated for viral infections but are used for secondary bacterial infection

Nursing Process: Care of the Patient with Pneumonia - Assessment Changes in temperature, pulse Secretions Cough Tachypnea, shortness of breath Changes in physical assessment, especially inspection, auscultation of chest Changes in CXR Changes in mental status, fatigue, dehydration, concomitant heart failure, especially in elderly patients

Nursing Process: Care of the Patient with Pneumonia - Diagnoses Ineffective airway clearance Activity intolerance Risk for fluid volume deficient Imbalanced nutrition Deficient knowledge

Collaborative Problems Continuing symptoms after initiation of therapy Shock Respiratory failure Atelectasis Pleural effusion Confusion Superinfection

Nursing Process: Care of the Patient with Pneumonia - Planning Improved airway clearance Maintenance of proper fluid volume Maintenance of adequate nutrition Patient understanding of treatment, prevention Absence of complications

Improving Airway Clearance Encourage hydration; 2 to 3 L a day, unless contraindicated Humidification may be used to loosen secretions By face mask or with oxygen Coughing techniques Chest physiotherapy Position changes Oxygen therapy administered to meet patient needs

Other Interventions Promoting rest Promoting fluid intake Encourage rest, avoidance of overexertion Positioning to promote rest, breathing (Semi-Fowler’s) Promoting fluid intake Encourage fluid intake to at least 2 L a day Maintaining nutrition Provide nutritionally enriched foods, fluids Patient teaching

Aspiration Risk factors Pathophysiology Prevention: Elevate HOB Turn patient to side when vomiting Prevention of stimulation of gag reflex with suctioning or other procedures Assessment, proper administration of tube feeding Rehabilitation therapy for swallowing

Pleural Conditions Pleurisy: inflammation of both layers of pleurae Inflamed surfaces rub together with respirations, cause sharp pain intensified with inspiration Pleural effusion: collection fluid in pleural space usually secondary to another disease process Large effusions impair lung expansion, cause dyspnea

Pleural Conditions (cont’d) Empyema: accumulation of thick, purulent fluid in pleural space. Patient usually acutely ill; fluid, fibrin development, loculation impair lung expansion Resolution is a prolonged process

Pleural Effusion

Causative Factors for Pulmonary Disease Cigarette smoking Air pollution

Acute Respiratory Distress Syndrome Severe form of acute lung injury Syndrome characterized by sudden, progressive pulmonary edema, increasing bilateral lung infiltrates on CXR, hypoxemia refractory to oxygen therapy, decreased lung compliance Symptoms Rapid onset of severe dyspnea Hypoxemia that does not respond to supplemental oxygen

Pathophysiology of ARDS

Management of ARDS Intubation, mechanical ventilation with PEEP to treat progressive hypoxemia Positioning: frequent position changes, proning Nutritional support General supportive care

Pulmonary Emboli Obstruction of pulmonary artery or branch by blood clot, air, fat, amniotic fluid, or septic thrombus Most thrombus are blood clots from leg veins Obstructed area has diminished or absent blood flow Although area is ventilated, no gas exchange occurs Inflammatory process causes regional blood vessels, bronchioles to constrict, further increasing pulmonary vascular resistance, pulmonary arterial pressure, right ventricular workload Ventilation-perfusion imbalance, right ventricular failure, shock occur

Risk Factors for Pulmonary Emboli Venous stasis Hypercoagulabilty Venous endothelial disease Certain disease states: heart disease, trauma, postoperative/postpartum, diabetes mellitus, COPD Other conditions: pregnancy, obesity, oral contraceptive use, constrictive clothing Previous history of thrombophlebitis

Thromboembolism P. Vessel Figure 39–6 A thromboembolism lodged in a pulmonary vessel.

Prevention and Treatment of Pulmonary Emboli Exercises to avoid venous stasis Early ambulation Anticoagulant therapy Sequential compression devices (SCDs) Treatment Measures to improve respiratory, CV status Anticoagulation, thrombolytic therapy

Umbrella Filter

Pneumoconioses Occupational lung diseases Cause of death of 124,846 people in United States (1968 to 2000) Causative agents Role of nurse as employee advocate Role of nurse in health education, teaching preventive measures Role of OSHA

Care of the Patient with Lung Cancer Prevention, causes Classification of lung cancer Treatment Surgery Radiation Chemotherapy Palliative care

Nursing Care of the Patient with Cancer Psychological support Pain Airway clearance Fatigue Dyspnea

Chest Trauma Blunt trauma Sternal, rib fractures Flail chest Pulmonary contusion Penetrating trauma Pneumothorax Spontaneous or simple Traumatic Tension pneumothorax

Flail Chest

Open Pneumothorax and Tension Pneumothorax

Management of Patients With Chronic Pulmonary Disease

COPD: Chronic Obstructive Pulmonary Disease A disease state characterized by airflow limitation that is not full reversible (GOLD). COPD is the currently is 4th leading cause of death and the 12th leading cause of disability. COPD includes diseases that cause airflow obstruction (emphysema, chronic bronchitis) or a combination of these disorders. Asthma is now considered a separate disorder but can coexist with COPD.

Pathophysiology of COPD Airflow limitation is progressive and is associated with abnormal inflammatory response of the lungs to noxious agents. Inflammatory response occurs throughout the airways, lung parenchyma, and pulmonary vasculature. Scar tissue and narrowing occurs in airways. Substances activated by chronic inflammation damage the parenchyma. Inflammatory response causes changes in pulmonary vasculature.

COPD Figure 39–2 The pathogenesis of chronic obstructive pulmonary disease.

Chronic Obstructive Pulmonary Disease Risk Factors Cigarette smoking Air pollution Occupational exposures Airway infection Familial and genetic factors

Chronic Bronchitis The presence of a cough and sputum production for at least 3 months in each of 2 consecutive years. Irritation of airways results in inflammation and hypersecretion of mucous. Mucous-secreting glands and goblet cells increase in number. Ciliary function is reduced, bronchial walls thicken, bronchial airways narrow, and mucous may plug airways. Alveoli become damaged, fibrosed, and alveolar macrophage function diminishes. The patient is more susceptible to respiratory infections.

Pathophysiology of Chronic Bronchitis

Emphysema: Abnormal distention of air spaces beyond the terminal bronchioles with destruction of the walls of the alveoli. Decreased alveolar surface area causes an increase in “dead space” and impaired oxygen diffusion. Reduction of the pulmonary capillary bed increases pulmonary vascular resistance and pulmonary artery pressures. Hypoxemia result of these pathologic changes. Increased pulmonary artery pressure may cause right-sided heart failure (cor pulmonale).

Changes in Alveolar Structure with Emphysema

Normal Chest Wall and Chest Wall Changes with Emphysema

Emphysema Figure 39–3 Typical appearance of a client with emphysema. Note the client’s anxious expression and assumption of the tripod position, leaning forward with the hands on the knees.

Typical Posture of a Person with COPD

Chronic Hypoxemia Figure 39–5 Clubbing of fingers caused by chronic hypoxemia.

Risk Factors for COPD Tobacco smoke causes 80-90% of COPD cases! Passive smoking Occupational exposure Ambient air pollution Genetic abnormalities Alpha1-antitrypsin

Nursing Process: The Care of Patients with COPD- Assessment Health history Inspection and examination findings Review of diagnostic tests

Nursing Process: The Care of Patients with COPD- Diagnoses Impaired gas exchange Impaired airway clearance Ineffective breathing pattern Activity intolerance Deficient knowledge Ineffective coping

Collaborative Problems Respiratory insufficiency or failure Atelectasis Pulmonary infection Pneumonia Pneumothorax Pulmonary hypertension

Nursing Process: The Care of Patients with COPD- Planning Smoking cessation Improved activity tolerance Maximal self-management Improved coping ability Adherence to therapeutic regimen and home care Absence of complications

Improving Gas Exchange Proper administration of bronchodilators and corticosteroids Reduction of pulmonary irritants Directed coughing, “huff” coughing Chest physiotherapy Breathing exercises to reduce air trapping diaphragmatic breathing pursed lip breathing Use of supplemental oxygen

Improving Activity Tolerance Focus on rehabilitation activities to improve ADLs and promote independence. Pacing of activities Exercise training Walking aides Utilization of a collaborative approach

Other Interventions Set realistic goals Avoid extreme temperatures Enhancement of coping strategies Monitor for and management of potential complications

Patient Teaching Disease process Medications Procedures When and how to seek help Prevention of infections Avoidance of irritants; indoor and outdoor pollution, and occupational exposure Lifestyle changes, including cessation of smoking

Bronchiectasis Bronchiectasis is a chronic, irreversible dilation of the bronchi and bronchioles. Caused by: Airway obstruction Diffuse airway injury Pulmonary infections and obstruction of the bronchus or complications of long-term pulmonary infections Genetic disorders such as cystic fibrosis Abnormal host defense (eg, ciliary dyskinesia or humoral immunodeficiency) Idiopathic causes

Bronchiectais: Clinical Manifestations Chronic cough Purulent sputum in copious amounts Clubbing of the fingers

Bronchiectasis: Medical Management Postural drainage Chest physiotherapy Smoking cessation Antimicrobial therapy

Bronchiectasis: Nursing Management Focuses on alleviating symptoms and clearing pulmonary secretions Patient teaching

Asthma A chronic inflammatory disease of the airways that causes hyperresponsiveness, mucosal edema, and mucous production. Inflammation leads to cough, chest tightness, wheezing, and dyspnea. The most common chronic disease of childhood. Can occur at any age. Allergy is the strongest predisposing factor.

Asthma Figure 39–1 The pathogenesis of an acute episode of asthma.

Asthma Incidence Risk Factors Prevalence of asthma currently relatively stable Hospitalizations and deaths due to asthma decreasing Risk Factors Allergies Family history Air pollution Occupational exposures Respiratory viruses Exercise in cold air Emotional stress

Medications Used for Asthma Quick-relief medications Beta2-adrenergic agonists Anticholinergics Long-acting medications Corticosteroids Long acting beta2-adrenergic agonists Leukotriene modifiers

Examples of Metered Dose Inhalers, and Spacers A Metered Dose Inhaler and Spacer in Use

Patient Teaching The nature of asthma as a chronic inflammatory disease Definition of inflammation and bronchoconstriction Purpose and action for each medication Identification of triggers and how to avoid them Proper inhalation techniques How to perform peak flow monitoring How to implement an action plan When and how to seek assistance

Using a Peak Flow Meter