Respiratory Review II

1. Respiratory Review II Ana H. Corona, MSN, FNP-C Nursing Instructor October 2007

2. What is a TB skin test? • A "TB Skin Test" is a test to see if TB germs are present in the body. • L.A. County uses the Mantoux method only for testing. Los Angeles County Department of Public Health Tuberculosis Control Program

3. Why would someone need a skin test? • A skin test is used to see if a person has been exposed and infected by M. tuberculosis or tubercle bacilli. • A test may also be required by an employer as an employment screening or to enter school.

4. What does a positive TB skin test result mean? • A positive skin test means that a person has been infected with TB germs sometime during that person's life. • It does not indicate that a person is contagious or symptomatic.

5. What should a person do if positive? • A person with a positive reaction requires further evaluation. • This person should be referred to a healthcare provider to have a chest x-ray or other clinical exams if indicated.

6. When should a TB test be examined? (read or checked) • The skin test should be examined (or read) 48-72 hours after it is administered. • It is acceptable to read the skin test up to 96 hours after administration if it is not possible to read it earlier. • After 96 hours, a skin test of less than 10 mm of induration should be repeated. • A skin test of 10 mm or more is positive at any time.

7. Should a person who had a BCG vaccination get a TB skin test? • Yes. Not all BCG vaccinations are effective. • A history of BCG vaccination does not exempt students or employees from the skin test.

8. What is latent TB infection? • A person with a positive skin test, no symptoms, and a normal X-ray has latent TB infection. • This person is NOT contagious.

9. When is TB contagious? • TB can be contagious in adolescents and adults, who are coughing, have a positive skin test, and an abnormal chest X-ray. • TB medications will make the person non-contagious very quickly. • Because of the efficacy of TB medicines, patients are not quarantined and are usually able to return to school or work within several weeks. 

10. Are children with active TB contagious? • Children under the age of 12 rarely have contagious TB. • This is because they have TB in a different area in the body and do not aerosolize or cough up their germs into the air.

11. Remember • People who have a positive TB skin test with a normal chest x-ray are NOT contagious, but may need medicine to prevent them from developing active TB.   • Children under the age of 12 with active TB are rarely contagious, and generally do not need to be kept out of school. 

12. Pneumonia • Pneumonia is an infection of the lungs. Many different organisms can cause it, including bacteria, viruses, and fungi. • Pneumonia can range from mild to severe, and can even be deadly. • The severity depends on the type of organism causing pneumonia, as well as your age and underlying health.

13. Causes • Pneumonia is a common illness that affects millions of people each year in the United States. • Bacterial pneumonias tend to be the most serious and, in adults, the most common cause of pneumonia. • The most common pneumonia-causing bacterium in adults is Streptococcus pneumoniae (pneumococcus). • Respiratory viruses are the most common causes of pneumonia in young children, peaking between the ages of 2 and 3. By school age, the bacterium Mycoplasma Pneumoniae becomes more common.

14. Pneumonia • In some people, particularly the elderly and those who are debilitated, bacterial pneumonia may follow influenza or even a common cold. • Many people contract pneumonia while staying in a hospital for other conditions. • This tends to be more serious because the patient's immune system is often impaired due to the condition that initially required treatment. • In addition, there is a greater possibility of infection with bacteria that are resistant to antibiotics.

15. The main symptoms of pneumonia are: • Cough with greenish or yellow mucus; bloody sputum happens on occasion • Fever with shaking chills • Sharp or stabbing chest pain worsened by deep breathing or coughing • Rapid, shallow breathing • Shortness of breath • Headache • Excessive sweating and clammy skin • Loss of appetite • Excessive fatigue • Confusion , especially in older people • Exams and Tests

16. Diagnostic Tests for Pneumonia • Chest x-ray • Gram's stain and culture of your sputum to look for the organism causing your symptoms • CBC to check white blood cell count; if high, this suggests bacterial infection • Arterial blood gases to check how well you are oxygenating your blood • CAT scan of the chest • Pleural fluid culture if there is fluid in the space surrounding the lungs

17. Pneumonia Treatment • If the cause is bacterial, the goal is to cure the infection with antibiotics. • If the cause is viral, typical antibiotics will NOT be effective, however sometimes your doctor may use antiviral medication. • In some cases it is difficult to distinguish between viral and bacterial pneumonia, so antibiotics may be prescribed.

18. Pneumonia • Many people can be treated at home with antibiotics. • Patients with chronic disease, severe symptoms, or low oxygen levels, you will likely require hospitalization for intravenous antibiotics and oxygen therapy. • Infants and the elderly are more commonly admitted for treatment of pneumonia.

19. Complications of Pneumonia • Empyema or lung abscesses are infrequent, but serious, complications of pneumonia. • They occur when pockets of pus form around or inside the lung. • These may sometimes require surgical drainage.

20. PreventionCohen J, Powderly WG. Infectious Diseases. 2nd ed. New York, NY: Elsevier, 2004. • Hand washing • Smoking Cessation: tobacco damages the lung's ability to ward off infection. • Vaccines can help prevent pneumonia in children, the elderly, and people with diabetes, asthma, emphysema, HIV, cancer, or other chronic conditions: • Pneumococcal vaccine (Pneumovax, Prevnar) prevents Streptococcus pneumoniae. • Flu vaccine prevents pneumonia and other infections caused by influenza viruses. • Hib vaccine prevents pneumonia in children from Haemophilus influenzae type b. • Taking deep breaths may help prevent pneumonia while recovering from surgery.

21. Influenza A & B (Flu) • The flu is a contagious infection of the nose, throat, and lungs caused by the influenza virus. • The flu usually begins abruptly, with a fever between 102 to 106°F. • Other common symptoms include a flushed face, body aches, and lack of energy. • The fever usually lasts for a day or two, but can last 5 days. • CDC Recommends Against the Use of Amantadine and Rimantadine for the Treatment or Prophylaxis of Influenza in the United States during the 2005-06 Influenza Season. Atlanta, Ga. U.S. Centers for Disease Control and Prevention; January 14, 2006.

22. Influenza • Somewhere between day 2 and day 4 of the illness, the "whole body" symptoms begin to subside, and respiratory symptoms begin to increase. • The flu virus can settle anywhere in the respiratory tract, producing symptoms of a cold, croup, sore throat, bronchiolitis, ear infection, or pneumonia.

23. The most prominent of the respiratory symptoms is usually a dry, hacking cough. • Most people also develop a sore throat and headache. • Nasal discharge and sneezing are common. • These symptoms (except the cough) usually disappear within 4-7 days. • Cough and tiredness usually last for weeks after the rest of the illness is over.

24. The flu usually arrives in the winter months. • The most common way to catch the flu is by breathing in droplets from coughs or sneezes. Symptoms appear 1-7 days later (usually within 2-3 days). • Because the flu spreads through the air and is very contagious, it often strikes a community all at once.

25. Anyone at any age can have serious complications from the flu, but those at highest risk include: • People over 50 • Children between 6 months and 2 years • Women more than 3 months pregnant during the flu season • Anyone living in a long-term care facility • Anyone with chronic heart, lung, or kidney conditions, diabetes, or weakened immune system

26. Fever - may be high Headache Tiredness Dry cough Sore throat Stuffy, congested nose Muscle aches and stiffness Nasal discharge Shortness of breath Wheezing Croupy cough Chills Fatigue Malaise Sweating Loss of appetite Vomiting Dizziness Worsening of underlying illness, such as asthma or heart failure Signs & Symptoms

27. Diagnostic Tests • If pneumonia is suspected, a chest x-ray. • Additional blood work may be needed. • They may include a complete blood count, blood cultures, and sputum cultures. • The most common method for diagnosing the flu is an antigen detection test, which is done by swabbing the nose and throat, then sending a sample to the laboratory for testing. • The results of these tests can be available rapidly, and can help decide if specific treatment is appropriate. However, the diagnosis can often be made by simply identifying symptoms without further testing.

28. Treatment • Rest • Medicines to relieve symptoms • Hydration • Avoid aspirin (especially teens and children) • Avoid alcohol and tobacco • Avoid antibiotics (unless necessary for another illness) • Antiviral medications If the flu is diagnosed within 48 hours of when symptoms begin, especially if you are high risk for complications

29. Antiviral Medications • Oseltamivir (Tamiflu) or zanamivir (Relenza), which are active against both influenza A and B. • Each of these medicines has different side effects and affects different viruses.

30. Oseltamivir is the best choice for children. It is available in a liquid formulation and may be easier to give to the child • Zanamivir is given inhaler and is not FDA-approved for children under age 12. • Treatment will only help if started early and only if the illness is actually influenza. It will not help treat a regular cold.

31. Complications • The flu goes away within 7 to 10 days. • Possible Complications: • Pneumonia • Encephalitis (infection of the brain) • Bronchitis • Sinus infections • Ear infections

32. Prevention • A flu shot can help lower one's chances of getting the flu. A flu shot is generally available to people who: • Are over 6 months old • Don't have a serious allergy to eggs • Haven't had a serious reaction to flu shots in the past • A new nasal spray-type flu vaccine called FluMist is available to people aged 5 to 49 years old. • FluMist uses a live, weakened virus instead of a dead one like the flu shot. • In one study, the nasal spray provided protection against the flu in up to 93% of children.

33. Lung CancerOnocology Nursing Society • Second most common cancer among both men and women and is the leading cause of cancer death for both. • In the 30-54 year age group, incidence rates among men are double those among women in most of the racial/ethnic groups. • An estimated 160,440 Americans will die in 2004 from lung cancer, accounting for 28% of all cancer deaths.

34. Lung Cancer Risk Factors • Diets low in fruits and vegetables may cause lung cancer. • Risk increases after the age of 45 and increases more dramatically after the age of 65. • Cigarette smoking accounts for nearly 90% of all lung cancers. • Smokers or former smokers with a 30-pack-year or greater history are at risk of lung cancer.

35. Pack Year • Pack year is the number of years someone has smoked multiplied by the number of packs smoked per day. • Example: A person with a 30-pack-year history will have smoked one pack of cigarettes per day for 30 years or three packs per day for 10 years. • Cigar smoking and pipe smoking also cause lung cancer. • Marijuana contains more tar than cigarettes, and the smoke is held in the lungs for a longer time. Marijuana is difficult to study because it is an illegal substance and many marijuana smokers also smoke cigarettes.

36. Risk Factors • Women smokers may have a higher risk of lung cancer than male smokers. • Passive smoking also contributes to the development of lung cancer among non-smokers. • Occupational exposures to asbestos and radon are linked with lung cancer. • Asbestos workers have a seven times greater risk of developing the disease. • Asbestos workers who smoke have a 50-90 times greater risk developing the disease.

37. Risk Factors • Air pollution also is a cause (small factor in incidence and mortality). • Lung cancer is a disease of older people. Lung cancer is fairly rare in people under 40. • If one stops smoking before lung cancer develops, damaged lung tissue gradually will return to normal. • Ten years after quitting, the risk is reduced to one-third of what it was previously.

38. Prevention & Screening • There is no widespread screening test for lung cancer. • At this time, the use of spiral CT scans are being studied for screening. • Eighty percent of lung cancers can be prevented by avoiding tobacco use.

39. Signs & Symptoms • Cough (persistent, dry) • Shortness of breath • Wheezing • Chest pain • Hemoptysis • Anorexia and weight loss • Frequent pneumonias

40. Other Signs & Symptoms • Fatigue • Chills • Swallowing difficulties • Hoarseness • Clubbing of the finger tips • Skin paleness or bluish discoloration • Muscle contractions or atrophy (shrinkage) • Joint pain • Facial swelling or paralysis • Eyelid drooping • Bone pain • Gynomastia

41. Lung Cancer Diagnostic Tests • Physical exam: A thorough physical examination with attention to the chest and thoracic lymph nodes and sputum sample. If sputum analysis does not provide a definite diagnosis, biopsy is required. • Chest X-ray • CT scan of the chest • MRI of the chest • MRI of the chest

42. Diagnostic Tests • Bronchoscopy: To obtain washings of the respiratory tissues. If the bronchoscopy is negative, proceed to a needle biopsy. • Needle biopsy: Fine needle aspiration (FNA) uses a slim, hollow needle that is attached to a syringe. Large needle or core biopsy uses a larger needle. Mediastinoscopy. Used to rule out metastatic disease and sample mediastinal nodes. • Tumor markers • PTH (parathyroid hormone) • CEA (carcinogenic antigen). A CEA level greater than 50 may indicates advanced diseases. • CYFRA21-1 (cytokeratin fragment 19)

43. Pathology • Non-small cell lung cancer (NSCLC) includes three histologies: • Epidermoid or squamous carcinoma • Adenocarcinoma • Large cell carcinoma

44. Nursing Diagnosis • Knowledge deficit r/t lung cancer • Anxiety • Pain • Impaired gas exchange • Impaired tissue integrity • Ineffective airway clearance • Anticipatory grieving • Risk for fluid volume excess

45. Treatment • The best way to treat lung lancer is to prevent it from happening in the first place. • A diagnosis of lung cancer is not a death sentence. • Effective treatment options are available.

46. Treatment by Stage • Stage 0 • Surgery alone. No chemotherapy or radiation therapy is needed. • Stage 1 and Stage 2 • Surgical resection. If margins are involved, RT recommended. If surgery is not feasible, radiation alone is an option.

47. Stage 3 • Stage 3 with abnormal and enlarged lymph nodes: No surgery. Recommend concurrent radiation and chemotherapy. • Stage 3 with normal mediastinal nodes: May proceed to surgery for tumor resection. In many patients, histopathologic examination will reveal that the lymph nodes are actually cancerous. May also have pre-op chemotherapy or chemo-radiotherapy and, if a response is seen, the patient may then go to surgery. • "Classic" Stage 3B: No surgery. A combination treatment plan with chemo-radiotherapy should be considered for those who have non-cancerous effusions.

48. Stage 4 • Chemotherapy alone versus palliative care. • Chemotherapy may help to relieve symptoms in patients who experience significant symptoms from their disease. • Chemotherapy options for stage 4 patients include: Paclitaxel (Taxol®) and carboplatin (Paraplatin®), as well as newer agents such as vinorelbine tartrate (Navelbine®), gemcitabine hydrochloride (Gemzar®), docetaxel (Taxotere®), and combinations of the above with cisplatin (Platinol®).

49. Oxygen Administration a. The goal for oxygen administration is to Improve or maintain systemic oxygenation (1) Increased oxygen saturation levels (a) Blood gas (b) Pluse oximetry (2) Less fatigue (3) Improved cognition (4) Less irritation

50. Oxygen Administration b. Nursing goals (1) Prevent complications (a) Dry mucus membranes (b) Infection (c) Obstruction Patient education increased understanding of and compliance with treatment (a) Reason for treatment (b) Safety issues (c) Activity restrictions (d) Stop smoking (e) Home care