Respiratory Respiratory DisordersDisorders

Respiratory Respiratory DisordersDisorders

Lola Oyedele MSN, RN, CTNLola Oyedele MSN, RN, CTNMajuvy L. Sulse MSN, RN, CCRNMajuvy L. Sulse MSN, RN, CCRN

LOWER AIRWAY AND LOWER AIRWAY AND PULMONARY VESSEL PULMONARY VESSEL

DISORDERSDISORDERS

LOWER AIRWAY AND LOWER AIRWAY AND PULMONARY VESSEL PULMONARY VESSEL

DISORDERSDISORDERSPneumoniaPneumonia

SARSSARSTuberculosisTuberculosis

Inhalation AnthraxInhalation AnthraxChronic Airflow LimitationChronic Airflow Limitation

Pneumonia • Excess of fluid in the lungs resulting

from an inflammatory process• Inflammation triggered by infectious

organisms and inhalation of irritants• Atelectasis• Hypoxemia

Pneumonia• Nosocomial or hospital-

acquired• Community acquired

Laboratory Assessment

• Gram stain, culture, and sensitivity testing of sputum

• Complete blood count• Arterial blood gas level• Serum blood, urea nitrogen level• Electrolytes• Creatinine

Impaired Gas Exchange

• Interventions include:– Cough enhancement– Oxygen therapy– Respiratory monitoring

Ineffective Airway Clearance

• Interventions include:– Help client to cough and deep

breathe at least every 2 hours.– Administer incentive spirometer—

chest physiotherapy if complicated.– Prevent dehydration.

(Continued)

Ineffective Airway Clearance (Continued)

– Monitor intake and output of fluids.

– Use bronchodilators, especially beta2 agonists.

– Inhaled steroids are rarely used.

Potential for Sepsis• Primary intervention is prescription

of anti-infectives for eradication of organism causing the infection.

• Drug resistance is a problem, especially among older people.

• Interventions for aspiration pneumonia aimed at preventing lung damage and treating infection.

Severe Acute Respiratory Syndrome

(SARS)• A virus from a family of virus types

known as “coronaviruses”• Virus infection of cells of the

respiratory tract, triggering inflammatory response

• No known effective treatment for this infection

• Prevention of spread of infection

Pulmonary Tuberculosis

• Highly communicable disease caused by Mycobacterium tuberculosis

• Most common bacterial infection• Transmitted via aerosolization• Initial infection multiplies freely in

bronchi or alveoli• Secondary TB• Increase related to the onset of HIV

Assessment

• Diagnosis of TB considered for any client with a persistent cough or other compatible symptoms (weight loss, anorexia, night sweats, hemoptysis, shortness of breath, fever, or chills)

• Bacillus Calmette-Guerin vaccine within previous 10 years produces positive skin test, complicating interpretation of TB test.

Clinical Manifestations of TB

• Progressive fatigue• Lethargy• Nausea• Anorexia

Clinical Manifestations of TB• Weight loss• Irregular menses• Low-grade fever, night sweats• Cough, mucopurulent sputum,

blood streaks

Diagnostic Assessment

• Manifestation of signs and symptoms• Positive smear for acid-fast bacillus• Confirmation of diagnosis by sputum

culture of M. tuberculosis• Tuberculin test (Mantoux test) purified

protein derivative given intradermally in the forearm

• Induration of 10 mm or greater diameter indicative of exposure

(Continued)

Diagnostic Assessment (Continued)

• Positive reaction does not mean that active disease is present, but does indicate exposure to TB or dormant disease.

Interventions

• Combination drug therapy strict adherence

• Isoniazid• Rifampin• Pyrazinamide• Ethambutol or streptomycin • Negative sputum culture indicative

of client no longer being infectious

Health Teaching• Follow exact drug regimen.• Proper nutrition must be

maintained.• Reverse weight loss and severe

lethargy.• Educate client about the

disease.

Lung Abscess• Localized area of lung destruction

caused by liquefaction necrosis, usually related to pyogenic bacteria

• Pleuritic chest pain• Interventions

• Antibiotics• Drainage of abscess• Frequent mouth care for Candida albicans

Inhalation Anthrax• Bacterial infection is caused by the

gram-positive, rod-shaped organism Bacillus anthracis from contaminated soil.

• Fatality rate is 100% if untreated.• Two stages are the prodromal

stage and the fulminant stage.• Drug therapy includes

ciprofloxacin, doxycycline, and amoxicillin.

Pulmonary Empyema

• A collection of pus in the pleural space• Most common cause: pulmonary

infection, lung abscess, and infected pleural effusion

• Interventions include:– Emptying the empyema cavity– Re-expanding the lung– Controlling the infection

Activity Intolerance

• Interventions to increase activity level:– Encourage client to pace activities

and promote self-care.– Do not rush through morning

activities.– Gradually increase activity.– Use supplemental oxygen therapy.

Interventions for Palliation

• Oxygen therapy• Drug therapy• Radiation therapy• Laser therapy• Thoracentesis and pleurodesis• Dyspnea management• Pain management

Chronic Airflow Chronic Airflow LimitationLimitation

Chronic Airflow Chronic Airflow LimitationLimitation

AsthmaAsthmaEmphysemaEmphysema

Chronic BronchitisChronic Bronchitis

Chronic Airflow Limitation

• Chronic lung diseases of chronic airflow limitation include:– Asthma– Chronic bronchitis– Pulmonary emphysema

• Chronic obstructive pulmonary disease includes emphysema and chronic bronchitis characterized by bronchospasm and dyspnea.

Asthma

• Intermittent and reversible airflow obstruction affects only the airways, not the alveoli.

• Airway obstruction occurs due to inflammation and airway hyperresponsiveness.

Aspirin and Other Nonsteroidal

Anti-Inflammatory Drugs

• Incidence of asthma symptoms after taking aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs)

• However, response not a true allergy• Results from increased production of

leukotriene when other inflammatory pathways are suppressed

Collaborative Management

• Assessment• History• Physical assessment and clinical

manifestations:– No manifestations between attacks– Audible wheeze and increased

respiratory rate– Use of accessory muscles– “Barrel chest” from air trapping

Laboratory Assessment

• Assess arterial blood gas level.• Arterial oxygen level may

decrease in acute asthma attack.• Arterial carbon dioxide level may

decrease early in the attack and increase later indicating poor gas exchange.

(Continued)

Laboratory Assessment (Continued)

• Atopic asthma with elevated serum eosinophil count and immunoglobulin E levels

• Sputum with eosinophils and mucous plugs with shed epithelial cells

Pulmonary Function Tests

• The most accurate measures for asthma are pulmonary function tests using spirometry including:– Forced vital capacity (FVC)– Forced expiratory volume in the first

second (FEV1)– Peak expiratory rate flow (PERF)– Chest x-rays to rule out other causes

Interventions • Client education: asthma is often an

intermittent disease; with guided self-care, clients can co-manage this disease, increasing symptom-free periods and decreasing the number and severity of attacks.

• Peak flow meter can be used twice daily by client.

• Drug therapy plan is specific.

Drug Therapy

• Pharmacologic management of asthma can involve the use of:

• Bronchodilators• Beta2 agonists

• Short-acting beta2 agonists

• Long-acting beta2 agonists

• Cholinergic antagonists(Continued)

Drug Therapy (Continued)

• Methylxanthines• Anti-inflammatory agents• Corticosteroids• Inhaled anti-inflammatory

agents• Mast cell stabilizers• Monoclonal antibodies• Leukotriene agonists

Other Treatments for Asthma

• Exercise and activity is a recommended therapy that promotes ventilation and perfusion.

• Oxygen therapy is delivered via mask, nasal cannula, or endotracheal tube in acute asthma attack.

Status Asthmaticus• Status asthmaticus is a severe, life-

threatening acute episode of airway obstruction that intensifies once it begins and often does not respond to common therapy.

• If the condition is not reversed, the client may develop pneumothorax and cardiac or respiratory arrest.

• Emergency department treatment is recommended.

Emphysema

• In pulmonary emphysema, loss of lung elasticity and hyperinflation of the lung

• Dyspnea and the need for an increased respiratory rate

• Air trapping, loss of elastic recoil in the alveolar walls, overstretching and enlargement of the alveoli into bullae, and collapse of small airways (bronchioles)

Classification of Emphysema

• Panlobular: destruction of the entire alveolus

• Centrilobular: openings occurring in the bronchioles that allow spaces to develop as tissue walls break down

• Paraseptal: confined to the alveolar ducts and alveolar sacs

Chronic Bronchitis

• Inflammation of the bronchi and bronchioles caused by chronic exposure to irritants, especially tobacco smoke

• Inflammation, vasodilation, congestion, mucosal edema, and bronchospasm

• Affects only the airways, not the alveoli• Production of large amounts of thick

mucus

Complications

• Chronic bronchitis• Hypoxemia and acidosis • Respiratory infections• Cardiac failure, especially cor

pulmonale• Cardiac dysrhythmias

Physical Assessment and Clinical

Manifestations

• Unplanned weight loss; loss of muscle mass in the extremities; enlarged neck muscles; slow moving, slightly stooped posture; sits with forward-bend

• Respiratory changes• Cardiac changes

Laboratory Assessment

• Status of arterial blood gas values for abnormal oxygenation, ventilation, and acid-base status

• Sputum samples• Hemoglobin and hematocrit blood

tests

• Serum alpha1-antitrypsin levels drawn

• Chest x-ray• Pulmonary function test

Impaired Gas Exchange

• Interventions for chronic obstructive pulmonary disease:– Airway management– Monitoring client at least every 2

hours – Oxygen therapy– Energy management

Drug Therapy• Beta-adrenergic agents• Cholinergic antagonists• Methylxanthines• Corticosteroids• Cromolyn sodium/nedocromil• Leukotriene modifiers• Mucolytics

Surgical Management• Lung transplantation for end-

stage clients• Preoperative care and testing• Operative procedure through a

large midline incision or a transverse anterior thoracotomy

• Postoperative care and close monitoring for complications

Ineffective Breathing Pattern

• Interventions for the chronic obstructive pulmonary disease client:– Assessment of client– Assessment of respiratory infection– Pulmonary rehabilitation therapy– Specific breathing techniques– Positioning to help alleviate

dyspnea– Exercise conditioning– Energy conservation

Ineffective Airway Clearance

• Assessment of breath sounds before and after interventions

• Interventions for compromised breathing:– Careful use of drugs– Controlled coughing– Suctioning – Hydration via beverage and

humidifier (Continued)

Ineffective Airway Clearance (Continued)

– Postural drainage in sitting position when possible

– Tracheostomy

Imbalanced Nutrition

• Interventions to achieve and maintain body weight:– Prevent protein-calorie

malnutrition through dietary consultation.

– Monitor weight, skin condition, and serum prealbumin levels.

– Address food intolerance, nausea, early satiety, loss of appetite, and meal-related dyspnea

Anxiety

• Interventions for increased anxiety:– Important to have client

understand that anxiety will worsen symptoms

– Plan ways to deal with anxiety

Health Teaching• Instruct the client:

– Pursed-lip and diaphragmatic breathing

– Support of family and friends– Relaxation therapy– Professional counseling access– Complementary and alternative

therapy

Potential for Pneumonia or Other Respiratory

Infections

• Risk is greater for older clients• Interventions include:

– Avoidance of large crowds– Pneumonia vaccination– Yearly influenza vaccine

Cystic Fibrosis • Genetic disease affecting many

organs, lethally impairing pulmonary function

• Present from birth, first seen in early childhood (many clients now live to adulthood)

• Error of chloride transport, producing mucus with low water content

• Problems in lungs, pancreas, liver, salivary glands, and testes

Nonpulmonary Manifestations

• Adults: usually smaller and thinner than average owing to malnutrition

• Abdominal distention• Gastroesophageal reflux, rectal

prolapse, foul-smelling stools, steatorrhea

• Vitamin deficiencies• Diabetes mellitus

Pulmonary Manifestations

• Respiratory infections• Chest congestion• Limited exercise tolerance• Cough and sputum production• Use of accessory muscles• Decreased pulmonary function• Changes in chest x-ray result• Increased anteroposterior diameter of

chest

Exacerbation Therapy

• Avoid mechanical ventilation• Airway clearance• Increased oxygenation• Antibiotic therapy• Heliox (50% oxygen, 50% helium)

therapy• Bronchodilator and mucolytic

therapies

Surgical Therapy

• Lung and/or pancreatic transplantation do not cure the disease; the genetic defect in chloride transport and the thick, sticky mucus remain.

• Transplantation extends life by 10 to 20 years.

• Single-lung transplant as well as double-lung transplantation is possible.

Primary Pulmonary Hypertension

• The disorder occurs in the absence of other lung disorders, and its cause is unknown although exposure to some drugs increases the risk.

• The pathologic problem is blood vessel constriction with increasing vascular resistance in the lung.

• The heart fails (cor pulmonale).• Without treatment, death occurs

within 2 years.

Interventions

• Warfarin therapy• Calcium channel blockers• Prostacyclin agents• Digoxin and diuretics• Oxygen therapy• Surgical management

Interstitial Pulmonary Disease

• Affects the alveoli, blood vessels, and surrounding support tissue of the lungs rather than the airways

• Restrictive disease: thickened lung tissue, reduced gas exchange, “stiff” lungs that do not expand well

• Slow onset of disease • Dyspnea common

Sarcoidosis

• Granulomatous disorder of unknown cause that can affect any organ, but the lung is involved most often

• Autoimmune responses in which the normally protective T-lymphocytes increase and damage lung tissue

• Interventions (corticosteroids): lessen symptoms and prevent fibrosis

Idiopathic Pulmonary Fibrosis

• Common restrictive lung disease• Example of excessive wound healing• Inflammation that continues beyond

normal healing time, causing extensive fibrosis and scarring

• Mainstays of therapy: corticosteroids, which slow the fibrotic process and manage dyspnea

Occupational Pulmonary Disease

• Can be caused by exposure to occupational or environmental fumes, dust, vapors, gases, bacterial or fungal antigens, or allergens

• Worsened by cigarette smoke• Interventions: special respirators

that ensure adequate ventilation

Lung Cancer

• A leading cause of cancer deaths worldwide

• Metastasizes at late-stage diagnosis• Paraneoplastic syndromes• Staged to assess size and extent of

disease• Etiology and genetic risk

(Continued)

Lung Cancer (Continued)

• Incidence and prevalence make lung cancer a major health problem.

• Health promotion and illness prevention is primarily through education strategies and reduced tobacco smoking.

Manifestations of Lung Cancer

• Often nonspecific, appearing late in the disease process

• Chills, fever, and cough• Assess sputum• Breathing pattern• Palpation• Percussion• Auscultation

Surgical Management• Lobectomy• Pneumonectomy• Segmentectomy (wedge

resection)

Pulmonary Embolism

• A collection of particulate matter—solids, liquids, or gases—enters venous circulation and lodges in the pulmonary vessels.

• In most people with pulmonary embolism, a blood clot from a deep vein thrombosis breaks loose from one of the veins in the legs or the pelvis.

Etiology • Prolonged immobilization• Central venous catheters• Surgery• Obesity• Advancing age• Hypercoagulability• History of thromboembolism• Cancer diagnosis

Health Promotion and Illness Prevention

• Stop smoking.• Reduce weight.• Increase physical activity.• If traveling or sitting for long

periods, get up frequently and drink plenty of fluids.

• Refrain from massaging or compressing leg muscles.

Clinical Manifestations

• Assess the client for:– Respiratory manifestations: dyspnea,

tachypnea, tachycardia, pleuritic chest pain, dry cough, hemoptysis

– Cardiac manifestations: distended neck veins, syncope, cyanosis, hypotension, abnormal heart sounds, abnormal electrocardiogram findings

– Low-grade fever, petechiae, symptoms of flu

Interventions • Evaluate chest pain• Auscultate breath sounds• Encourage good ventilation and

relaxation

(Continued)

Interventions (Continued)

• Monitor the following:– respiratory pattern– tissue oxygenation– symptoms of respiratory failure– laboratory values–effects of anticoagulant medications

• Surgery

Decreased Cardiac Output

• Interventions include:– Intravenous fluid therapy– Drug therapy

•Positive inotropic agents•Vasodilators

Risk for Injury (Bleeding)

• Interventions include:– Protect client from situations that

could lead to bleeding.– Closely monitor amount of

bleeding.– Assess often for bleeding,

ecchymoses, petechiae, or purpura.

– Examine all stool, urine, nasogastric drainage, and vomitus and test for occult blood.

Anxiety • Interventions include:

– Oxygen therapy– Communication– Drug therapy: anti-anxiety

agents