1. Management of Patients With Chest and Lower Respiratory Tract Disorders

2. 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

3. 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

4. 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

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

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

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

9. 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.

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

11. Diagnostic Tests
Chest x-ray
Sputum examination

13. 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

14. 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

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

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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. Pleural Effusion

24. Causative Factors for Pulmonary Disease
Cigarette smoking
Air pollution

25. 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

26. Pathophysiology of ARDS

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

28. 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

29. 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

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

31. 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

32. Umbrella Filter

33. 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

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

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

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

37. Flail Chest

38. Open Pneumothorax and Tension Pneumothorax

39. Management of Patients With Chronic Pulmonary Disease

40. 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.

41. 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.

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

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

44. 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.

45. Pathophysiology of Chronic Bronchitis

46. 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).

47. Changes in Alveolar Structure with Emphysema

49. Normal Chest Wall and Chest Wall Changes with Emphysema

50. 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.

51. Typical Posture of a Person with COPD

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

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

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

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

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

58. 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

59. 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

60. 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

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

62. 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

63. 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

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

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

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

67. 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.

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

70. 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

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

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

73. 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

74. Using a Peak Flow Meter