Care of the Chronic Respiratory Client

1. Care of the Chronic Respiratory Client Keith Rischer RN, MA, CEN

2. Todays Objectives • Compare & contrast pathophysiology and clinical manifestations of asthma, emphysema, bronchitis & lung cancer. • Identify the diagnostic tests, nursing priorities, and client education with asthma, emphysema, bronchitis, & lung cancer. • Describe the mechanism of action, side effects and nursing responsibilities with pharmacologic management of asthma, emphysema & bronchitis. • Contrast and compare medical vs. surgical management for treatment of lung cancer. • Identify nursing priorities and care of the client with a chest tube. • Identify nursing priorities and care of the client on a mechanical ventilator.

4. COPD Increase resistance to airflow Bronchi smooth muscle innervated by autonomic nervous system Parasympathetic stimulation Sympathetic stimulation Inflammatory mediator response COPD Chronic-recurrent obstruction Emphysema bronchitis Obstructive Airway Disorders

5. Obstructive Disorders:Asthma • Patho • Intermittent & reversible airway obstruction • INFLAMMATION-Chronic • Antibody molecules (IgE) • Mast cells>histamine>WBC • Physiological response to inflammation • Vessel dilation>capillary leakage>tissue swelling>incr. secretions • Airway hyper-responsiveness • Childhood • Allergens • smoking • Cold/dry air • Bacteria • Bronchospasm • edema & mucous

6. What is a Mast Cell? • Bag of Granules • Located in connective tissue • close to blood vessels • Histamine released • Increase blood flow • Increase vascular permeability • Binds to H1, H2 receptors

7. Etiology of asthma • Intrinsic etiologies • uncertain causes • physical or psychological stress • exercise-induced • Extrinsic etiologies • antigen-antibody (allergic) reaction to specific irritants • air pollutants • sinusitis • cold and dry air • Meds-ASA • food additives • hormonal influences • GE reflux

8. Clinical manifestations of Asthma Severe dyspnea wheezing with expiration or inspiration Which is worse… Tachypnea Cough Feelings of chest tightness Prolonged expiration Diminished breath sounds Increased heart rate and blood pressure Restlessness, anxiety, agitation

9. Asthma: Lab & Dx Findings Decreased pO2 Decreased pCO2 Early Late findings Elevated eosinophil count CXR Pulmonary Function Test Forced vital capacity (FVC) Peak flow meter ABG’s pH 7.28 pO2-55 pCO2-60 HCO3-22 O2 sats-86% RA ABG’s pH 7.35 pO2-75 pCO2-30 HCO3-22 O2 sats-90% RA

10. Pharmacologic Treatment Options • Relievers = short-acting bronchodilators • quickly relieves bronchoconstriction and symptoms • Controllers = daily medications taken on a long-term basis • useful for controlling persistent asthma • includes anti-inflammatory agents and long-acting bronchodilators

11. Beta-2 agonists chart 33-5 p.590-592 • Mechanism • bronchodilation through bronchial smooth muscle relaxation mediated by beta-2 receptors in the lung • Short Acting • albuterol (Proventil, Ventolin) • Xopenex • Pirbuterol (Maxair autoinhaler) • Terbutaline (Brethaire) • Long acting • Salmeterol-Serevent • Onset: 5-15 minutes • Duration: 4-6 hours

12. Beta-2 agonists • Uses: • Rescue medication to relieve acute symptoms & prevention of bronchospasms prior to a precipitating event (e.g. exercise) • Adverse effects: • Tachycardia • Restlessness • Tremors • Palpitations • paradoxical bronchoconstriction

13. Anticholinergics • Mechanism • block parasympathetic nervous system influence • SNS dominates • Ipratropium (Atrovent) • Onset: 3-30 minutes, peak: 1-2 hours • Duration: 4-8 hours • Adverse effects • drying of mouth and respiratory secretions • increased wheezing in some individuals

14. Inhaled Corticosteroids • Mechanism • Decrease inflammation • block late reaction to allergens and reduce airway hyperresponsiveness • inhibit microvascular leakage • Common Meds…used qd • budesonide (Pulmocort) • fluticasone (Flovent) • triamcinolone (Azmacort)

15. Inhaled Corticosteroids (cont.) • Uses: • long-term prevention of symptoms (suppression, control, and reversal of inflammation) • reduce/eliminate oral steroid use • Adverse effects: • oral candidiasis • ??systemic effects at high doses

16. Oral Corticosteroids • Common agents • Prednisone • methylprednisolone (Medrol, Solu-Medrol) • Uses • short term (3-10 days) “burst therapy” to gain prompt control of asthma • to prevent progression of exacerbation, speed recovery, and reduce relapse • long-term prevention of symptoms in severe persistent asthma • LT Side Effects • HTN • Peptic ulcers • Skin fragility • Impaired immunity • Thromboembolism • Cushingoid appearance

17. Asthma:Combination Inhalers • Advair Diskus • Fluticasone • Salmeterol (serevent) • Frequency • 1 inhalation q12 hours • Combivent MDI • Ipratropium (atrovent) • Albuterol • Frequency • 2 puffs 4 times daily

18. Asthma: Other Medications • Leukotriene Antagonists • anti-inflammatory • Montelukast (Singulair) • Therapeutic response • Decreased frequency & severity of attacks • Decreased exercise induced bronchoconstriction • Mast cell stabilizers • Mechanism • Cromolyn sodium (Intal) • Frequency • 1-2 inhalations 4 times daily

19. Asthma:Regimen by Severity Mild Short-acting beta-agonist inhaler Anti-inflammatory inhaler used for mild symptoms occurring daily Moderate Anti-inflammatory inhaler plus medium-dose corticosteroid inhaler used for moderate symptoms occurring daily or more often Severe Anti-inflammatory inhaler plus long-acting bronchodilator plus oral corticosteroid used for severe symptoms occurring daily or more often

20. Priority Nursing Diagnoses for Asthma Impaired gas exchange r/t… Ineffective breathing pattern r/t… Ineffective airway clearance r/t… Anxiety r/t… Deficient knowledge

21. Asthma:Critical Care Management • Status asthmaticus/severe asthma • Physical assessment • Dyspnea/tachypnea • Wheezing I/E • Diminished aeration to no air movement • Accessory muscles • Medical management …remember A,B,C,s • O2 • Albuterol neb • Epinephrine subq • Establish IV • IV steroids (solumedrol) • Prepare for possible intubation

22. Planning and implementation for Asthma Assess respiratory and oxygenation status Administer supplemental oxygen as needed Administer broncholdilators as prescribed Observe characteristics of sputum Identify/avoid/remove precipitating factors Teach patient relaxation techniques Prepare for IV access Be prepared for intubation Diagnostic studies Emotional support for patient and family

23. Expected outcomes/evaluation Absence of dyspnea, chest tightness, wheezing Respiratory rate 12-20 breaths per minute Pulse oximetry/arterial blood gas values within normal range for client Bilaterally clear and equal breath sounds Afebrile Adequate airway clearance Absence/resolution of anxiety Clear chest x-ray or return to patient’s baseline Normal or improved peak flow

24. Asthma: Patient Education Identify asthma triggers Teach patient/family proper used of metered-dose inhaler Chart 33-6 p.593 Rescue inhalers! Instruct client regarding the use of peak flow meter for self-assessment of asthma status Asthma symptoms requiring emergency intervention

25. Emphysema

26. Emphysema: Patho • Loss of lung elasticity • Alveolar destruction • Excessive enlargement • Loss of “curves” impairs gas exchange • Compensation… • Hyperinflation of lung • Secondary to air trapping • “barrel chest” appearance • “Pink puffer • O2 diffused easier than CO2 • CO2 accumulates causing chronic resp. acidosis

27. Emphysema: Causes & Complications Cigarette smoking Pack years required Smoke>enzyme elastase protease>destroys alveoli Destroys cilia Chronic respiratory inflammation air pollution Complications Hypoxemia & acidosis Resp. infections/pneumonia Cur pulmonale Cardiac dysrhythmias

28. Emphysema: PhysicalAssessment…A,B,C’s • General appearance • Emaciated • Barrel chest • Airway/breathing • Dyspnea • Tachypnea • Accessory muscle use • Pursed lip breathing • Lung sounds • overall diminished, and wheezes or crackles may be present • Dry cough more so than productive • O2 sats… • Circulation • tachycardia (inadequate oxygenation) • Arrythmias

29. Emphysema: Diagnostic Tests ABGs Chronic resp. acidosis Compensation w/HCO3 Assess pO2, pCO2 and HCO3 CBC WBC Hgb Hct polycythemia Chest x-ray hyperinflated lungs with a flattened diaphragm ABG’s pH 7.35 pO2-55 pCO2-60 HCO3-22 O2 sats-86% RA ABG’s pH 7.35 pO2-55 pCO2-60 HCO3-35 O2 sats-86% RA

30. ED COPD Case Study • 84yr female • PMH: COPD, asthma, HTN, anxiety, mitral stenosis • HPI: productive cough of green phlegm the last 4 days. Primary MD started on po Prednisone and Abx. • Developed incr. SOB through the night with pronounced fever/chills w/left shoulder pain that increases w/movement. Denies CP • VS: T-103.2 P-122 (ST) R-36 BP-202/105 sats 88% RA • Assessment: • Neuro-a/o notably anxious • Resp-diminished bilat w/exp. Wheezing • CV-2/6 murmur

31. ED COPD Case Study • Medical Priorities… • Nursing priorities • Nursing assessments… • Nursing interventions…

32. ED COPD Case Study • CXR • Large left lower lobe infiltrate • Labs • BMP • Na 138, K+ 3.9, creat. 1.16, gluc 112 • CBC • WBC 7.0, Hgb 13.3, Hct 39.9, plat. 217 • UA • neg

33. Chronic Bronchitis • A disorder of chronic airway inflammation • Major & small bronchioles • Chronic productive cough lasting at least 3 months during 2 years • Chronic exposure to irritants • smoking • An inflammatory response in the small & large airways resulting in… • Vasodilation • Congestion • mucosal edema • broncospasm

34. Chronic Bronchitis: Patho • Etiology • Smoking • Chronic inflammation • Increase in # and size of mucous glands • More mucous • bronchial walls thicken/edema • airflow is impeded • Smaller airways are blocked • Airflow and gas exchange impacted • pO2… • pCO2… • Cilia disappear, and the airway clearance function is lost • Unlike emphysema, cannot increase breathing efforts to maintain blood gases • “blue bloater” • Polycythemia

35. Chronic Bronchitis: Clinical Manifestations Productive cough Primarily occurring during winter season foul-smelling sputum Dyspnea and activity intolerance Frequent pulmonary infections “Blue bloater” bluish-red skin discoloration from cyanosis and polycythemia Barrel chest

36. Emphysema/Bronchitis:Medical Management Goals improve ventilation promote patent airway by removal of secretions Remove environmental pollutants O2 and neb therapy Chest physiotherapy Mechanical ventilation Surgical procedure bullectomy lung volume reduction lung transplantation

37. Emphysema/Bronchitis: Medications Beta-adrenergic agonists bronchodilators in COPD by nebs or MDI Anticholinergics Atrovent administered as maintenance by inhaler most effective bronchodilators for COPD Theophylline may be beneficial to strengthen diaphragm contractility and decrease work of breathing Corticosteroids may be beneficial for pts. w/asthma history Immunizations flu and pneumonia Abx

38. Emphysema/Bronchitis: Priority Nursing Dx p.600-606 Impaired gas exchange r/t… Ineffective breathing pattern r/t… Ineffective airway clearance r/t… Imbalanced nutrition r/t… Anxiety r/t… Activity intolerance r/t… Fatigue r/t… Deficient knowledge

39. Emphysema/Bronchitis: Nursing Care Priorities remember A,B,C’s… Administer low-flow O2 as needed Position patients to maintain effective breathing Closely monitor & assess resp. status Auscultation O2 sats Response to acute interventions/O2 Provide education and referrals for pts. w/risk behaviors Referral to smoking cessation Pulmonary conditioning program Develop appropriate nutritional plans Energy conservation Exercise conditioning Assess understanding to education

40. Emphysema/Bronchitis: Patient Education Smoking cessation Teach clients how to avoid occupational or environmental pollutants Pursed lip breathing Maintain adequate nutrition with emphasis on higher calorie intake Nutrition may be optimal with frequent small meals, and 1000-2000cc of fluid daily Teach energy conservation techniques

41. Emphysema/Bronchitis: Expected Outcomes Activity tolerance is optimized Pulmonary irritants such as smoking, air pollution, or occupational exposure are avoided Pulmonary infections are reduced in number and severity Nutritional intake is adequate but not excessive for individual energy needs

42. Pulmonary Tuberculosis • Patho • Mycobacterium tuberculosis (bacillus) • Most common bacterial infection globally • Aerosolized • Susceptible host • Nonspecific pneumonitis alveoli or bronchus • 5-15% ultimately develop • Cell mediated immunity 2-10 weeks later w/+ mantoux

43. Pulmonary Tuberculosis: Infection • Inflammation in lungs surrounded by lymphocytes, collagen • Caseation necrosis • Necrotic tissue turned into granular mass that become calcified • Seen in low to middle lobes • Can spread systemically to brain, liver , kidneys, bone marrow

44. Incidence • HIV • Immigrant populations • Crowded areas • LTC, prison, • Elderly • Homeless • Poverty

45. Physical Assessment/Diagnosis • Fatigue, lethargy, nausea, weight loss • Fever…night sweats • Persistent cough…productive streaked w/blood • Decreased aeration, crackles • Diagnosis • Positive smear acid-fast bacillus • + sputum culture…takes 1-3 weeks to confirm • Mantoux 5-10mm induration

46. Treatment chart 34-7 p.643 • Combination • Isoniazid (INH) • Rifampin • Pt. education • Compliance! 6 months treatment required • Sputum specimens q2-4 weeks during therapy • No longer contagious after 2-3 weeks of treatment • Once negative x3 cured

47. Nursing Priorities • Airborne precautions • Ventilated room • N-95 mask or PAPR for any staff entering room • TB drugs can cause nausea-anticipate • Nutrition

48. Lung Cancer: Patho • Bronchial epithelium • 90% primary • Obstruction • Histologic cell type • Small cell vs. non small cell • Small cell 20% of all lung CA • 99% correlation w/smoking • Adenocarcinoma • 35% of all lung CA • Spread between smokers and non smokers • Metastasis • Circulatory & lymphatic

49. Lung Cancer: Clinical Manifestations • Non-specific & occur late • Depend on type & location of tumor • Bronchitis/pneumonitis secondary to obstruction • Chills • Fever • Cough • Bloody sputum • Dyspnea • Use of accessory muscles • Wheezing-diminished aeration

50. Lung Cancer: Diagnostic • CXR • CT • Bronchoscopy • Bronchial washing • Needle/surgical biopsy