Respiratory Tract Disorders

1. Assessment & Management of Patients With Respiratory Tract Disorders

2. Lower Respiratory Tract • Trachea • Bronchi • Bronchioles • Alveoli • Cilia

3. Respiratory anatomy

4. Alveoli at the terminal end of the lower airway

5. Clinical Manifestations 1. Local Manifestations • Cough • chronic, paroxysmal, dry , productive • Excessive Nasal Secretion • Expectoration of Sputum • mucoid, purulent, mucopurulent, rusty, hemoptysis • Pain • pleuritic, intercostal, generalized chest pain • Dyspnea- shortness of breath

6. Function Gases are moved in and out of the lung through pressure changes. Intrapleural pressure is negative (less than atmospheric pressure – 760mmHg) Please refer to suggested reading notes

7. Clinical Manifestations 2. Systemic Manifestations • Hypoxemia • insufficient oxygenation of the blood • cyanosis- bluish, grayish discoloration of skin & mucous membranes • Hypoxia • inadequate tissue oxygenation • Hypercapnia • CO2 in arterial blood above normal limits • Hypocapnia • CO2 in arterial blood below normal limits • Respiratory Failure

8. Medical Terminology (Respiratory conditions) • Respiratory Failure: The inability of the cardovascular and pulmonary systems to maintain an adequate exchange of oxygen and carbondioxide in the lungs. • Maybe caused by a failure in oxygen or in ventilation. • Can be hypoxemic or hypercapneic.

9. Medical terminology cont. • Ventilation: the process of moving gases into and out of the lungs Work of Breathing: The effort required for expanding and contracting of the lungs. The influencing factors: the rate and depth of breathing, the ease in which the lungs can be expanded and airway resistance

10. Assessment of Respiratory System Health History • Risk Factors • Major Clinical Manifestations • Cough • Sputum production • Chest pain • Wheezing • Clubbing of the fingers • Cyanosis

11. Assessment of Respiratory System Physical Examination • Inspection • posture, shape, movement, dimensions of chest, flared nostrils, use of accessory muscles, skin color, and rate, depth, & rhythm of respiration • Palpation • respiratory excursion, masses, tenderness • Percussion • flat, dull, resonant, hyperresonant sounds • Auscultation • breath sounds, voice sounds, crackles, wheezes

12. Crackles

13. Diagnostic Procedures • Sputum Studies • Methods- standard, saline inhalation, gastric washing • Arterial Blood Gases • measurements of blood pH , arterial O2 & CO2 tensions, acid-base balance • Pulse Oximetry • Chest X-ray • Bronchoscopy • Thoracentesis • Laryngoscopy

15. Lower Respiratory Disorders

16. Pneumonia • Inflammation & infection of lung- infecting organisms typically inhaled- organisms transmitted to lower airways and alveoli causing inflammation- impairs gas exchange Etiology: bacteria, virus, Mycoplasma, fungus, or from aspiration or inhalation of chemicals or other toxic substances • Risk factors: cigarette smoking, chronic underlying disorders, severe acute illness, suppressed immune system, & immobility

18. Pneumonia Assessment: Questions to ask • Have you been experiencing difficulty breathing? • Are you having pain? Where? • Do you have a cough? • Have you been running a fever? • Have you been feeling tired? Clinical Manifestations: • fever, pleuritic chest pain, tachypnea, SOB, tachycardia, cough, sputum production- rusty, blood-tingled or yellow-green, fatigue, poor appetite

19. Pneumonia Diagnostic: • Sputum and blood cultures, CBC, ABGs, CXR, & Bronchoscopy Nursing Diagnoses: • Ineffective airway clearance sec. to thick, tenacious sputum • Ineffective breathing pattern sec.to tachypnea, chest pain, & airway inflammation • Impaired gas exchange sec. to exudate in alveoli • Activity intolerance sec. to hypoxemia, fatigue • Acute pain sec.to disease process

20. Pneumonia Planning: Client Outcomes • Maintain open & clear airway, normal RR, PO2 level without supplemental O2, complete physical care without frequent rest periods Interventions • Improve airway patency- auscultate lung sounds, monitor ABGs or pulse oximetry, elevate HOB, C & DB q 2hrs, ambulate , O2 as needed • Promote fluid intake & promote activity tolerance • Monitor & prevent complications • High fowler’s positioning to facilitate air exchange

21. Pneumonia • Pharmacology: • Antibiotic therapy based on sputum culture & sensitivity • Levaquin, Tequin, Rocephin, Primaxin, Zithromax, Ketek, Zinacef, Cipro, Tetracycline • Instruct to finish all antibiotics at prescribed intervals • Short acting beta 2 agonist such as Salbutamol • Corticosteroids ,Prednisolone to decrease inflammation • Influenza vaccine, pneumococcal vaccine

22. Period of bed rest • Promote adequate nutrition • Provide support • Evaluation: • breathing easier without chest pain • temperature normal, • activity level increased without frequent rest periods

23. ARDS Acute Respiratory Disease Syndrome • A form of Acute Lung Injury • Diffused alveolar injury • An acute condition characterized by bilateral pulmonary infiltrates and severe hypoxemia • Build up fluid in alveolar

25. ARDS - Causes • Breathing vomit into lungs (aspirations) • Inhaling chemicals • Lung transplannt • Pneumonia • Septic shock (infection thru body) • Trauma

26. ARDS -Characterstics • Stiff heavy lungs(decreases the lungs ability to expand) • The level of oxygen in the blood can stay dangerously low (even if oxygen is given via a ventilator)

27. ARDS - Symptoms • Symptoms usually develop 24 to 48 hrs of illness or injury • Dyspnoea • Low blood pressure (infection) and organ failure • Rapid breathing

28. ARDS - Diagnostics • Arterial Blood Gas • Blood Tests • Blood and Urine cultures • Bronchoscopy • Chest x-ray Sputum culture and analysis

29. ARDS - Treatment • Intensive Care Admission • Antibiotic therapy • Steroid therapy • Diuretics • Ventilatory support

30. PULMONARY EMBOLISM • Is a complication of an underlying venous thrombosis • Patient may not show classic signs and symptoms

31. PE – SIGNS AND SYMPTOMS • Classic presentation: • Pleuretic chest pain • Dyspnoea • Hypoxia

32. PE – Signs and symptoms • Seizures • Syncope • Abdominal pain • Fever • Productive cough • Wheezing • Altered level of consciousness

33. PE – Signs and Symptoms • New onset of atrial fibrillation • Hemoptysis • Flank pain • Delirium

34. PE - Diagnosis • ECG • Chest xray, CT, MRI, Echo, VQ scan • Blood tests –Dimer, coagulation profile, Arterial blood gas

35. PE - Management • Anticoagulation (warfarin, heparin, retaplse) • Surgical intervention : • Emoblectomy • Vena Cava filters

36. TUBERCULOSIS • Infectious disease that primarily affects the lungs; may be transmitted to other parts of the body • Pulmonary infiltrates accumulate, cavities develop, & masses of granulated tissue form within the lungs • Primary infectious agent- Mycobacterium Bacilli Transmitted by inhalation of droplets (talking, coughing, sneezing, & singing) • Risk factors: immune system disorder, preexisting medical conditions, institutionalized, health care workers

37. Pulmonary Tuberculosis • Mycobacterium tuberculosis • Airborne transmission • Tuberculin skin testing • Pharmacologic therapy- multi-drug regimens and prophylaxis

38. Tuberculosis Assessment: • Questions to ask - Are you suffering from night sweats? Have you lost weight? Have you been having low-grade fever? Have you been having SOB and coughing up anything from your lungs? Have you had chest pain? Where? Have you had weight loss? Clinical Manifestations- low-grade fever (late afternoon), night sweats, weight loss, anorexia, fatigue, chronic productive cough,pleuritic chest pain, hemoptysis

39. Tuberculosis Diagnostic: • Sputum culture- + acid-fast bacilli (AFB) • Skin testing • CBC- WBC elevated • CXR • Bronchoscopy Nursing Diagnosis: • Ineffective airway clearance r/t thick, tenacious secretions • Ineffective breathing pattern r/t airway inflammation

41. Tuberculosis • Altered nutrition less than body requirements sec. to anorexia and fatigue • Fatigue sec. to disease process • Anxiety sec. to social isolation secondary to isolation protocols Planning: Clients Outcomes • Maintain clear airway,normal RR, achieve weight gain, anxiety decreased Interventions: • Maintain respiratory isolation- infectious period - diversional activities • Barrier protection should be used

42. Evaluation: • Client adheres to isolation precautions, takes medication as prescribed Complications • Miliary TB The organism invade the blood stream and can spread to multiple body organ • Meningitis • Pericarditis

43. Tuberculosis • Promote airway clearance- bedrest, increase fluid intake, high humidity • Pharmacology • First-line meds- Isoniazid, Rifampin, Ehtambutol, & Pyrazinamide for 4 months • Isoniazid and Rifampin continued for an additional 2 months or up to 12 months. • Advocate adherence & prevention • Monitor and manage potential complications • Adequate nutrition • Provide client and family education • Provide emotional support

44. Tuberculosis • Questions to ask • Do you have difficulty breathing- all the time or is it caused by exertion? • Do you cough frequently and is it productive? • Have you had a weight loss? • Do you feel tired quite often and are your activities impaired by SOB or fatigue? • Do you have many respiratory infections? Over what period of time?

45. Tuberculosis Nursing Diagnosis • Ineffective airway clearance r/t thick, tenacious secretion and fatigue • Ineffective breathing pattern r/t fatigue and obstruction of the bronchial tree • Impaired gas exchange r/t increased sputum production • Activity intolerance r/t hypoxemia & fatigue • Altered nutrition r/t increased metabolic demands, fatigue, & anorexia • Anxiety r/t inability to breathe effectively

46. Tuberculosis Diagnostics: • ABGs, CBC, sputum culture, CXR, Pulmonary function tests Planning: Client Outcomes • Effectively clear airway and breathing pattern, maintain normal ABGs, increase activity with decrease SOB or fatigue, maintain weight, and less anxious with episodes of SOB

47. Bronchitis • Inflammation of the bronchi caused by irritants or infection • hypertrophy & hypersecretion of mucous- cause increase in sputum production • increase mucous- decrease airway lumen size- lumen becomes colonized with bacteria. • Bronchial wall becomes scarred - leads to stenosis & airway obstruction • Defined as a productive cough that lasts 3 months a year for 2 consecutive years with other causes excluded. • Cough in the morning with sputum production is indicative of Chronic Bronchitis

49. Bronchitis Risk Factors: cigarette smoking, exposure to pollution, hazardous airborne substances Clinical Manifestations: productive cough, dyspnea esp. on exertion, wheezing, use of accessory muscles to breathe, cyanosis- “blue bloater”, clubbed fingers Interventions: • Assess patency of airway- suction if cough ineffective, RR, accessory muscle use, lung sounds, skin color changes, ABGs • Encourage high fluid intake & instruct in effective breathing & coughing • Monitor oxygen administration & aerosol therapy

50. Chronic Bronchitis • Encourage to report sputum changes or worsening of symptoms • Encourage exercise to improve resp. fitness • Counsel to avoid respiratory irritants and stop smoking • Immunize against common flu and pneumonia Pharmacology: • Antibiotic therapy- Tequin, Levaquin • Bronchodilators- Albuterol, Combivent, Theophylline • Corticosteroids- Prednisone, Solumedrol