Management of Patients With Chest and Lower Respiratory Tract

Disorders

Management of Patients With Chest and Lower Respiratory Tract

Disorders

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

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

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

Respiratory Infections

• Acute tracheobronchitis• Pneumonia– Community-acquired pneumonia– Hospital-acquired pneumonia– Pneumonia in immunocompromised host– Aspiration pneumonia

Risk Factors

• Cancer, smoking, COPD (produce mucus, or obstruct bronchus

• Immunocompromised pt• Prolonged immobility and shallow

breathing• Depressed cough reflex, aspiration of

foreign material

• Alcoholism• GA, sedative• Advance age• Respiratory therapy with improperly

cleaned equipment• Transmission of organisms from staff of

health care.

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.

• Orthopnea• Decrease appetite, fatigue• Purulent sputum• Crackles, increased tactile fermitus,

dullness on percussion, bronchial breathing sounds, egophony and whispered pectoriloquy.

Diagnostic Tests

• Chest x-ray• Sputum examination

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

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

Nursing Process: Care of the Patient with Pneumonia - Diagnoses

• Ineffective airway clearance• Activity intolerance• Risk for fluid volume deficient• Imbalanced nutrition• Deficient knowledge

Collaborative Problems

• Continuing symptoms after initiation of therapy

• Shock• Respiratory failure• Atelectasis• Pleural effusion• Confusion• Superinfection

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

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

Other Interventions

• Promoting rest – 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

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

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

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

Pleural Effusion

Causative Factors for Pulmonary Disease

• Cigarette smoking• Air pollution

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

Pathophysiology of ARDS

Management of ARDS

• Intubation, mechanical ventilation with PEEP to treat progressive hypoxemia

• Positioning: frequent position changes, proning

• Nutritional support • General supportive care

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

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

Thromboembolism P. Vessel

Prevention and Treatment of Pulmonary Emboli

• Prevention– Exercises to avoid venous stasis– Early ambulation– Anticoagulant therapy– Sequential compression devices (SCDs)

• Treatment– Measures to improve respiratory, CV status – Anticoagulation, thrombolytic therapy

Umbrella Filter

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

Care of the Patient with Lung Cancer

• Prevention, causes• Classification of lung cancer• Treatment– Surgery– Radiation– Chemotherapy

• Palliative care

Nursing Care of the Patient with Cancer

• Psychological support• Pain• Airway clearance• Fatigue • Dyspnea

Chest Trauma

• Blunt trauma• Sternal, rib fractures• Flail chest• Pulmonary contusion• Penetrating trauma• Pneumothorax– Spontaneous or simple– Traumatic– Tension pneumothorax

Flail Chest

Open Pneumothorax and Tension Pneumothorax

Management of Patients With Chronic Pulmonary Disease

Management of Patients With Chronic Pulmonary Disease

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.

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.

COPD

Chronic Obstructive Pulmonary Disease

• Risk Factors– Cigarette smoking – Air pollution– Occupational exposures– Airway infection– Familial and genetic factors

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.

Pathophysiology of Chronic Bronchitis

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).

Changes in Alveolar Structure with Emphysema

Normal Chest Wall and Chest Wall Changes with Emphysema

Emphysema

Typical Posture of a Person with COPD

Chronic Hypoxemia

Risk Factors for COPD

• Tobacco smoke causes 80-90% of COPD cases!• Passive smoking• Occupational exposure• Ambient air pollution• Genetic abnormalities– Alpha1-antitrypsin

Nursing Process: The Care of Patients with COPD- Assessment

• Health history• Inspection and examination findings • Review of diagnostic tests

Nursing Process: The Care of Patients with COPD- Diagnoses

• Impaired gas exchange • Impaired airway clearance• Ineffective breathing pattern• Activity intolerance• Deficient knowledge• Ineffective coping

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

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

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

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

Other Interventions

• Set realistic goals• Avoid extreme temperatures• Enhancement of coping strategies• Monitor for and management of potential

complications

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

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

Bronchiectais: Clinical Manifestations

• Chronic cough• Purulent sputum in copious amounts• Clubbing of the fingers

Bronchiectasis: Medical Management

• Postural drainage• Chest physiotherapy• Smoking cessation• Antimicrobial therapy

Bronchiectasis: Nursing Management

• Focuses on alleviating symptoms and clearing pulmonary secretions

• Patient teaching

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.

Asthma

Asthma • Incidence– 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

Medications Used for Asthma

• Quick-relief medicationsBeta2-adrenergic agonists– Anticholinergics

• Long-acting medicationsCorticosteroids– Long acting beta2-adrenergic agonists– Leukotriene modifiers

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

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

Using a Peak Flow Meter