SP 2014 Signs and Symptoms of Pulmonary Disease

SP 2014

Signs and Symptoms of Pulmonary Disease • Dyspnea – Subjective sensation of uncomfortable breathing – “unable to get enough air” – “breathlessness” – Air hunger – Shortness of breath

Signs and Symptoms of Pulmonary Disease • Factors contributing to Dyspnea – Increased work of breathing – Respiratory muscle fatigue – Decreased breathing reserve – Strong emotions • Anger • Anxiety

Signs and Symptoms of Pulmonary Disease • Signs of dyspnea – Flaring nostrils – Use of accessory muscles of respirations – Retraction of the intercostal spaces – Dyspnea on exertion • Frequently first episode

Signs and Symptoms of Pulmonary Disease • Orthopnea • Dyspnea when lying down • Horizontal position causes redistribution of body water causing abdominal contents to exert pressure on diaphragm • Generally relieved by sitting up

Signs and Symptoms of Pulmonary Disease • Paroxysmal Nocturnal Dyspnea (PND) – Waking up at night gasping for air and must sit up to relieve the dyspnea – Individuals with LVF – Results from fluid in the lungs caused by the redistribution of body water while the individual is recumbent

Signs and Symptoms of Pulmonary Disease • Eupnea – Normal breathing – Rhythmic and effortless – Rate is 8 to 16 breaths per minute – Tidal volume is 400 -800 mls. – Sighs 10 -12 times per hour

Signs and Symptoms of Pulmonary Disease • Kussmaul Respirations (hyperpnea) – Slightly increased ventilatory rate – Very large tidal volume – No expiratory pause

Signs and Symptoms of Pulmonary Disease • Cheyne-Stokes Respirations – Alternating periods of deep and shallow breathing – Apnea lasting 15 -60 seconds is followed by ventilations that increase in volume until a peak is reached, after which ventilation (tidal vol. ) decreases again to apnea – Problem with brain stem

Signs and Symptoms of Pulmonary Disease • Restricted Breathing – Commonly from restricted pulmonary disease (pulmonary fibrosis) stiff lungs – Characterized by small VT (tidal Vol. ) – Rapid ventilatory rate (tachypnea)

Signs and Symptoms of Pulmonary Disease • Obstructive Breathing – Slow ventilatory rate – Large tidal vol. – Increased effort – Prolonged inspiration and expiration – Audible Wheezing or Stridor

Signs and Symptoms of Pulmonary Disease • Hypoventilation – Inadequate alveolar ventilation in relation to metabolic demands – Caused by alterations in pulmonary mechanics or neurologic control of breathing – Hypercapnea (increased CO 2)

Signs and Symptoms of Pulmonary Disease • Hyperventilation – Alveolar ventilation exceeds metabolic demands – Hypocapnia – Severe anxiety – Acute head injury – Conditions that cause insufficient oxygenation of the blood

Signs and Symptoms of Pulmonary Disease • Cough – Explosive expiration – Protective reflex – Cleans lower airways – Stimulated by irritant receptors in the airway – Effectiveness depends on depth of inspiration – Persistent cough indicates disorder or disease

Signs and Symptoms of Pulmonary Disease • Cough (continued) – Acute nonproductive cough indicates bronchitis or viral pneumonia – Dry cough can be caused by Aspiration – Persistent Dry Cough can be caused by tumor, congestion, or hypersensitive airways – Purulent sputum indicates infection – Nonpurulent sputum indicates irritation – Remember that people will swallow their sputumdoesn’t mean it is nonproductive

Signs and Symptoms of Pulmonary Disease • Hemoptysis – coughing up blood or bloody secretions – Bright red – Has alkaline p. H – Localized abnormality (infection or inflammation) that damages bronchi- Bronchitis, Bronchiectasis – Lung parenchyma- tuberculosis, lung abscess – Cancer – Pulmonary infarction

Signs and Symptoms of Pulmonary Disease • Hemoptysis (continued) – Coughing up blood or bloody secretions – Not to be confused with Hematemesis (vomiting up blood) dark, acidic, and mixed with food particles – Blood coughed up is usually bright red, alkaline, and mixed with frothy sputum – Hemoptysis indicates a localized abnormality, usually infection or inflammation that damages the bronchi (bronchitis, bronchiectasis)

Signs and Symptoms of Pulmonary Disease • Cyanosis – Bluish discoloration of the skin and mucous membranes – Caused by increasing amounts of desaturated or reduced hemoglobin – Can be caused by pulmonary or cardiac right-toleft shunts, decreased cardiac output, cold environments, or anxiety – Lack of cyanosis does not necessarily indicate that oxygenation is normal

Signs and Symptoms of Pulmonary Disease • Cyanosis (continued) – If present, Pa. O 2 should be measured because cyanosis can mean conditions causing low saturated hemoglobin but not necessarily! – Peripheral cyanosis is best seen in nail beds

Signs and Symptoms of Pulmonary Disease • Pursed-lip Breathing – COPD – Asthma – (Increased) breathlessness – Strategy taught to slow expiration – (Decreased) dyspnea

Signs and Symptoms of Pulmonary Disease • Tripod Position; inability to lie flat – COPD – Asthma in exacerbation – Pulmonary edema – Indicates moderate to severe respiratory distress

Signs and Symptoms of Pulmonary Disease • Accessory muscle use; intercostal retractions – COPD – Asthma in exacerbation – Secretion retention – Severe respiratory distress – hypoxemia

Signs and Symptoms of Pulmonary Disease • Splinting – Voluntary decrease in tidal volume to decrease pain on chest expansion – Thoracic or abdominal incision – Chest trauma – pleurisy

Signs and Symptoms of Pulmonary Disease • Wheezing – May or may not be heard by patient – May be described as chest tightness • Pleuritic Chest Pain – Described on a continuum from discomfort during inspiration to intense, sharp pain at the end of inspiration. – Pain is usually aggravated by deep breathing and coughing.

Signs and Symptoms of Pulmonary Disease • Voice Change – Hoarseness – Stridor – Muffling – Barking cough – Upper airway abnormality – Vocal cord dysfunction – Gastroesophageal disease

Signs and Symptoms of Pulmonary Disease • Tachypnea – Fever – Anxiety – Hypoxemia – Restrictive lung disease – Magnitude of Increased above normal rate reflects increased work of breathing

Signs and Symptoms of Pulmonary Disease • Tracheal Deviation – Nonspecific indicator of change in position of mediastinal structures – Medical emergency if caused by tension pneumothorax

• Altered tactile fremitus – Increase or decrease in vibrations – Increased in pneumonia, pulmonary edema – Decreased in pleural effusion, atelectasis, lung hypoinflation – Absent in in pneumothorax, large atelectatic area

Signs and Symptoms of Pulmonary Disease • Altered Chest Movement – Unequal movement – Atelectasis – Pneumothorax – Pleural effusion – Splinting

Signs and Symptoms of Pulmonary Disease • Hyperresonance – Lung hyperinflation (COPD) – Lung collapse (pneumothorax) – Air trapping (asthma) – Increased density (pneumonia, large atelectasis) – Fluid pleural space (pleural effusion) What else do you see?

Signs and Symptoms of Pulmonary Disease • Pain – Caused by pulmonary disorders originates in the pleura, airways, or chest wall. – Pleural pain is most common pain caused by pulmonary disease – Infection and inflammation of the parietal pleura causes the pleura to stretch during inspiration – Pleural friction rub can be heard over painful area

Signs and Symptoms of Pulmonary Disease • Pain (continued) – Laughing, coughing makes pain worse – Pleural pain is present in pulmonary embolism – Pulmonary pain is central pain that worsens after cough and occurs with infection and inflammation of the trachea or bronchi

Signs and Symptoms of Pulmonary Disease • Clubbing – Bulbous enlargement of the end of the digit – Usually painless – Commonly associated with diseases that interfere with oxygenation • Lung cancer • Bronchiectasis • Cystic Fibrosis • Pulmonary fibrosis • Lung abcess • Congenital heart disease

Signs and Symptoms of Pulmonary Disease • Abnormal Sputum – Color, consistency, odor, amount of sputum vary with different pulmonary disorders – Changes in amount and consistency of sputum provide information about progression of disease and effectiveness of therapy

Abnormal Sputum • Healthy" phlegm is normally clear or white. • Yellow phlegm - sign of an infection, or common cold. • The initial state of the common flu when the phlegm is still clear is the most infectious period. When the phlegm turns into yellow, the body is already taking care of the infection. • Greenish or brownish phlegm is nearly always a sign of infection. • Greenish or rusty phlegm or phlegm with rusty spots can also be a sign of pneumonia and/or internal micro-bleedings.

• Coughing up brown phlegm is also a common symptom of smoking. This is due to resin sticking to the viscous texture of the phlegm and being ejected by the body. • Another type of phlegm often associated with smoking is brownish gray in color. • This variant is encased in clear saliva. When spread out, the brown-gray "core" is shown to be grainy in composition, as opposed to holding together. • This is simply dust and other foreign matter and may be caused by damage to the cilia, as in COPD patients.

• Gray sputum – comes from a cold or flu Gray sputum – might be hay fever too Yellow sputum – it might be bronchitis Yellow sputum – or bronchiectasis Black sputum – could be from smoking crack Black sputum – a nasty thing to hack Red sputum – blood’s somewhere in the tree Red sputum – think CA or TB Orange sputum – might be Pneumococcus Orange sputum – or Klebsiella pus Green sputum – think Pseudomonas first Green sputum – Mycoplasma’s the worst

Conditions Caused by Pulmonary Disease or Injury • Hypercapnia – Increased carbon dioxide in the arterial blood (increased Pa. CO 2) – Caused by hypoventilation • Depression of the respiratory center by drugs • Diseases of the medulla • Abnormalities of the spinal conducting pathways

Conditions Caused by Pulmonary Disease or Injury • Diseases of the neuromuscular junction • Diseases of the respiratory muscles • Thoracic cage abnormalities • Large airway obstructions • Increased work of breathing or physiologic dead space

Conditions Caused by Pulmonary Disease or Injury • Hypoxemia – Reduced oxygenation of arterial blood – Caused by respiratory alterations • Hypoxia – Reduced oxygenation of cells in tissues

Conditions Caused by Pulmonary Disease or Injury • Causes of Hypoxemia – Decreased oxygen content (PO 2) of inspired gas – Hypoventilation – Diffusion abnormalities – Abnormal ventilation-perfusion ratios – Pulmonary right-to-left shunt

S/S of Inadequate Oxygenation • Respiratory – Tachypnea early – Dyspnea on exertion early – Dyspnea at rest late – Use of accessory muscles late – Retraction of interspaces on inspiration late – Pause for breath between sentences, words late

S/S of Inadequate Oxygenation • Cardiovascular – Tachycardia early – Mild hypertension early – Arrhythmias (PVCs) early or late – Hypotension late – Cyanosis late – Cool, clammy skin late

S/S of Inadequate Oxygenation • Central Nervous System – Unexplained apprehension early – Unexplained restlessness or irritability early – Unexplained confusion or lethargy early or late – Combativeness late – Coma late

S/S of Inadequate Oxygenation • Other – Diaphoresis early or late – Decreased urinary output early or late – Unexplained fatigue early or late

Signs and Symptoms of Pulmonary Disease • Fine Crackles – Interstitial fibrosis (asbestosis) – Interstitial edema (early pulmonary edema) – Alveolar filling (pneumonia) – Loss of lung volume (atelectasis) – Early phase of congestive heart failure

Signs and Symptoms of Pulmonary Disease • Coarse Crackles – Congestive heart failure – Pulmonary edema – Pneumonia with severe congestion – COPD

Signs and Symptoms of Pulmonary Disease • Rhonchi – COPD – Cystic fibrosis – Pneumonia – bronchiectasis

Signs and Symptoms of Pulmonary Disease • Wheezes – Bronchospasm (asthma) – Airway obstruction (foreign body, tumor) – COPD

Signs and Symptoms of Pulmonary Disease • Stridor – Croup – Epiglottitis – Vocal cord edema after extubation – Foreign body

Signs and Symptoms of Pulmonary Disease • Absent breath Sounds – Pleural effusion – Main-stem bronchi obstruction – Large atelectasis – Pneumonectomy – lobectomy

Signs and Symptoms of Pulmonary Disease • Pleural Friction Rub – Pleurisy – Pneumonia – Pulmonary infarct

Epistaxis • All ages – Trauma – Foreign bodies – Nasal spray abuse – Anatomic malformations – Allergic rhinitis – tumors • Any condition that: – prolongs bleeding time – Alters platelet counts – Requires ASA or NSAIDs – Causes HTN

Epistaxis (continued) – Keep patient quiet – Sitting position, leaning forward – Apply direct pressure, pinching entire soft portion for 10 -15 minutes, if continues digital pressure – Apply ice compresses to nose – Suck on ice – Partially insert gauze – Vasoconstrictive agents, cauterization, anterior packing (antibiotic impregnated ribbon for 48 -72 hours

Epistaxis (continued) • Posterior packing- hospitalization required – May alter consciousness – May alter respiratory status, especially in elderly – Hypoventilation – Inflatable balloons

Epistaxis (continued) – Nursing Care • Monitor respiratory rate, heart rate, rhythm • Monitor oxygen saturation • Monitor Level of Consciousness • Observe for signs of aspiration • Observe for signs of infection – Predisposes to Staphlococcus aureus • Packing is painful! – Tylenol with Codeine

Epistaxis (continued) • Failure to work after 3 days requires surgery • Patient Discharge Instructions – Avoid vigorous nose blowing – Avoid strenuous activity, lifting, straining for 46 weeks – Sneeze with the mouth open – Avoid ASA or NSAIDs

Cancer of the Larynx – 90% from prolonged tobacco and alcohol use – 10% exposure to noxious fumes and chemicals – Link to EBV – 9, 000 new cases/year – 3, 700 deaths – Male-to-female ratio is 3: 1 – Increasing with smoking and alcohol consumption getting equal among genders

Cancer of the Larynx – 5% of all cancers – Disability issues are great • Loss of voice • Disfigurement • Social consequences – Early detection is key to survival

Cancer of the Larynx • Clinical Manifestations • Varies with tumor location • May be painless • Ulcer that doesn’t heal • Change in the fit of dentures • Persistent unilateral sore throat, ear pain • Lump in neck • Hoarseness • change in voice • Dysphagia • Thickening of soft oral mucosa

Cancer of the Larynx • Nursing Assessment – Subjective Data – + family history – Prolonged tobacco use – Exposure to radiation or occupational exposures to heavy metals and fumes – History of viral infections (EBV) – Poor oral hygiene – Prolonged use of OTC medication for sore throat, decongestants

Cancer of the Larynx • Objective Data – Gastrointestinal • White (leukoplakia) or Red (erythroplakia) patches inside mouth • Ulceration of mucosa • Asymmetric tongue • Exudate in mouth or pharynx • Foul breath • Mass or thickening of mucosa

Cancer of the Larynx • Objective Data – Respiratory • Hoarseness • Change in voice quality • Chronic laryngitis • Nasal voice • Palpable neck mass and lymph nodes (tender, hard, fixed) • Tracheal deviation • Dyspnea and stridor (late sign)

Cancer of the Larynx • Objective Data – Unplanned weight loss – General debilitated state

Cancer of the Larynx • Diagnostic studies for the detection of cancer of the head and neck – Mass on direct or indirect Laryngoscopy – Flexible nasopharyngoscope – Visual inspection – Tumor on soft tissue X-ray – CT Scan or MRI to detect local or regional spread – + Biopsy specimens

Cancer of the Larynx • Staging of the tumor (TNM) – Primary tumor (T) • TX, T 0, Tis, T 1, T 2, T 3, T 4 – Regional Lymph Nodes • NX, N 0, N 1, N 2, N 3 – Distant Metastasis • MX, M 0, M 1

Cancer of the Larynx – Radiation therapy – Surgery • Partial Laryngectomy (early stage, small portion) • Supraglottic Laryngectomy (hyoid, glottis, false cord) • Hemilaryngectomy (subglottic area, tracheostomy and NG tube in place for 2 weeks, difficulty swallowing and aspiration) • Total Laryngectomy (entire laryngeal structure removed including epiglottis, tracheal parts) – Major cervical lymphatic vessels and lateral cervical space with preservation of nerves, spinal accessory nerves, and internal jugular vein

Cancer of the Head and Neck • Surgery – Radical neck Dissection • Both sides • Little preservation • Radiation • Many patients refuse to undergo

Cancer of the Head and Neck – Expected Patient Outcomes • Patent airway • No spread of cancer • No complications related to therapy • Adequate nutritional intake • Minimal to no pain • Ability to communicate acceptable body image

Nursing Diagnosis: Cancer of the Head and Neck • Anxiety related to lack of knowledge: • Surgical procedure • Pain management • Prevention of complications – Assess knowledge desired by patient – Provide information • What to expect after surgery (tracheostomy tube, pain management, alternative communication methods, nasogastric tube, drainage tube – Decreases sense of helplessness; increases sense of control

Nursing Diagnosis: Cancer of the Head and Neck • Ineffective Airway Clearance: • Alteration in upper airway, tracheal stoma, presence of tracheostomy tube, difficulty expectorating sputum, ineffective cough – Auscultate chest / monitor RR, pattern, Sp. O 2, level of Consciousness – Encourage coughing and deep breathing – Humidified air or oxygen – Clean inner cannula of tracheostomy/ laryngectomy frequently

Nursing Diagnosis: Cancer of the Head and Neck • Altered Tissue Perfusion: • Tissue edema • Disruption of vascular and lymphatic drainage – Maintain HOB at 30 -40 degrees – Monitor HR, BP, H&H to detect bleeding – Monitor patency of tubes and drains – Monitor amount, color of drainage – Clean incision to prevent infection

Nursing Diagnosis: Cancer of the Head and Neck • Altered Nutrition: • • Surgical procedure Edema Dysphagia Presence of N-G tube – Provide frequent oral hygiene (rinses) – Administer enteral feedings – Clear liquids, advance as tolerated – Monitor caloric intake – Weigh patient

Nursing Diagnosis: Cancer of the Head and Neck • Impaired Verbal Communication: • Removal of vocal cords – Evaluate patient’s ability to write – Alternative methods (slate, board, electrolarynx) – Encourage use of communication tools – Allow time to communicate – Consult with speech therapist • Esophageal speech

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Nursing Diagnosis: Cancer of the Head and Neck • Body Image Disturbance: • Disfiguring surgery • Loss of oral communication – Assess patient’s body image concept – Encourage attention to personal hygiene – Encourage socialization with family and friends – Provide info on improving appearance (high collars) – Answer questions honestly – Involve patient (and family) in self-care – Assure patient of self-worth, increase acceptance of personal appearance

Nursing Diagnosis: Cancer of the Head and Neck • Pain: • Surgical procedure – Assess patient’s manifestations (facial expressions, reluctance to cough, move) – Administer pain medication – Logroll head and chest (prevent strain on sutures) – Keep HOB at 30 -40 degrees – Refer patient to physical therapy

Nursing Diagnosis: Cancer of the Head and Neck • Ineffective management of Therapeutic Regimen: – Provide written instructions – Teach patient and family laryngectomy tube and stoma care – repeat teachings with return demos – Teach to cover stoma with other hygiene activities (shaving, makeup, etc. ) – Teach to report changes (stoma narrowing, difficulty swallowing, lump in throat, etc. )

Nursing Diagnosis: Cancer of the Head and Neck • Ineffective management of Therapeutic Regimen: – Teach patient to provide adequate humidity at home (bedside humidifier, sitting in steamy bathroom, instillation of 3 -5 ml sterile normal saline) – Teach patient to report changes in mucous production – Make referral for home health care visit to evaluate self-care

Acute Bronchitis • • Inflammation of the lower respiratory tract Usually due to infection Occurs frequently in chronic respiratory disease Usually sequela of URI Usually self-limiting Usually viral- sometimes strep or Haemophilus Common in smokers and non-smokers

• Cough Acute Bronchitis – persistent – Production of clear, mucoid sputum – Sometimes purulent – Associated symptoms • Fever • Headache • Malaise • No consolidation on x-ray

• Treatment Acute Bronchitis – Supportive – Increase fluids – Rest – Cough suppressants – No antibiotics unless smoker or COPD

Chronic Bronchitis • • Persistent inflammation of LRT Without infection Type of COPD Acute exacerbations with acute infections Could be lethal Empirical broad-spectrum antibiotics Teach to recognize early S/S

Chronic Bronchitis • Inflammation of the bronchi • Caused by irritants or infection • Characterized by mucous gland hyperplasia and muscle hypertrophy, bronchial wall thickening, inflammation • Consequences- narrowing of the bronchial lumen • Caused by excess mucous, thickening of the airway walls, leads to obstruction

Chronic Bronchitis • Pathophysiology – Hypersecretion of mucous/chronic production – Cough – Continues at least 3 mos/yr – Twenty times in smokers – Elderly – Repeated infections are common

Chronic Bronchitis • Initially chronic bronchitis affects only the larger bronchi, but eventually all airways are involved • Thick mucous, hypertrophied bronchial smooth muscle obstruction • Walls become inflamed, thickened, edematous

Chronic Bronchitis • Diagnosis is based on physical exam, CXR, pulmonary function tests, and ABG • Prevention is best treatment • Not reversible • Bronchodilators increase airway caliber • Expectorants improve secretion removal and maximzes gas exchange

Chronic Bronchitis Chest PT Prophylactictic antibiotic therapy Steroids Low flow O 2 for severe hypoxemia and CO 2 retention • High flow O 2 causes chemoreceptors to no longer act as the primary stimulus for breathing • •

Inhalation Injuries • • Gaseous irritants Toxic gases Smoke Ammonia and hydrogen chloride Chlorine Phosgene Nitrogen dioxide

Inhalation Injuries • Causes severe inflammation • Treatment includes oxygen and ventilation, PEEP or PS • Support Cardiovascular

Aspiration • • “went down the wrong pipe” Fluid or solid particles into lungs Food or other stuff like gasoline (story) Impaired swallowing Impaired cough mechanism Decreased LOC CNS abnormalities

Aspiration • Altered LOC from substance abuse, sedation, anesthesia, seizures, CVA, Myasthenia Gravis, Guillian-Barre Syndrome, tracheoesophageal fistula (communicates) • Right lung more susceptible to aspiration than left lung • Branching angle of right bronchus more straight

Aspiration • Effects of Aspiration depends on material aspirated – Solid foods or materials can obstruct – Might needed to be removed by bronchoscopy – May develop chronic local inflammation which may lead to recurrent infection and bronciectasis (permanent dilation of bronchus)

Aspiration • Surgical resection of affected area may be needed • Aspiration of acidic gastric fluid may cause pneumonitis

Aspiration • Bronchial damage includes: – Inflammation – Loss of ciliary function – Bronchospasm – Damage to the alveolocapillary membrane and allows plasma and blood cells to move from capillaries into the alveoli, resulting in hemorrhagic pneumonitis

Aspiration • Serous transudate into lung causes systemic hypoventilation and hypotension • Lung becomes stiff and noncompliant as surfactant production is disrupted • Edema and collapse

Aspiration • Preventive measurements – NPO before surgery – Antacids can be used to keep p. H>2. 5 – Positioning when eating with extreme caution – Nasogastric tubes remove stomach contents – Chronic-gastric tube

Aspiration • Treatment – Supplemental oxygen – Mechanical ventilation with PEEP with suctioning – Bronchoscopy – Fluids restricted to decrease blood vol. And decrease pulmonary edema – Steriods 1 st 72 hours after aspiration and decreases inflammation – Antibiotics-bacterial pneumonia could develop

Atelectasis • Collapse of lung tissue (alveoli) • Can be caused by: – External pressure by tumors, fluid, air in pleural space – By abdominal distention pressing on portion of lung – Causes alveoli to collapse

Absorption Atelectasis • Results from removal of air from obstructed or hypoventilated alveoli • Inhalation of concentrated oxygen or anesthetic agents • Clinical manifestations – Similar to those of pulmonary infection – Dyspnea – Cough – Fever – leukocytosis

Absoption Atelectasis • Typically occurs after surgery – Immobility, reluctant to change position – Pain, breaths shallowly – High-dose supplemental oxygen – Anesthesia – Produces viscous secretions that tend to pool in dependent portion of the lung after surgery-especially in the thorax and abdomen

Absoption Atelectasis • Prevention and treatment – Deep breathing- incentive spirometry-cough opens airways, promotes secretion clearance – Early ambulation

Pneumonia • • Acute inflammation of lung parenchyma Leading cause of death until 1936 Sulfa and Penicillin Still common High mortality rate with some types 1% of population in U. S. during their lives 6 th leading cause of death in U. S.

Pneumonia • • Filtration of air Warming and humidification Epiglottis closure over trachea Cough reflex Mucociliary escalator mechanism Secretion of immunoglobulin A Alveolar macraphages Natural defenses of the lung

Pneumonia • Acquisition of Organisms – Aspiration of normal inhabitants of the pharynx – Inhalation of microbes – Hematogenous spread from elsewhere in the body

Pneumonia • Hospital-acquired • Community-acquired – 600, 000 cases annually • 48 hours or longer admission • 10 cases per 1000 – Streptococcus • Highest morbidity and mortality rate of any nosocomial infections pneumoniae – Pseudomonas – Haemophilus influenzae – Enterobacter – Legionella – Staph aureus – Mycoplama – Strep pneumoniae – Chlamydia

Pneumonia • Aspiration Pneumonia – AKA necrotizing pneumonia – Follows aspiration of substance – Loss of consciousness • Seizure, anesthesia, head injury, alcohol intake – Gag and cough depressed – Dependent portion of lung – Triggers inflammation, obstruction, infection in 48 -72 hours

Pneumonia • Opportunistic Pneumonia – Altered immune response – Severe protein-calorie malnutrition – Immune deficiencies – Transplants – Radiation – Chemotherapy – Corticosteroids • Pneumocystis carinii

Pneumonia • Pathophysiology – Congestion- outpouring of fluid into alveoli – Red hepatization- massive dilation of the capillaries and alveoli filled with organisms, neutrophils, RBCs, and fibrin – Lung appears red and granular (liverlike) – Resolution- exudate becomes lysed, processed by macrophages. – Normal lung tissue restored

Pneumonia • Clinical Manifestations – Sudden onset of fever, chills, cough is productive to purulent – Pleuritic chest pain – Consolidation • Dullness to percussion • Bronchial breath sounds • Crackles • Increased fremitus • Sore throat • vomiting

Pneumonia • Complications – Pleurisy (inflammation of the pleura) – Pleural Effusion ( 1 -2 weeks) – Atelectasis (collapsed, airless alveoli) – Delayed resolution in older, malnourished, alcoholic, or COPD patients – Lung Abscess seen in S. aureus most often – Empyema (accumulation of purulent exudate in pleural cavity)

Pneumonia • Pericarditis results from spread to pericardium • Arthritis results from systemic spread to affected joints (red, swollen, painful, purulent exudate can be aspirated) • Meningitis caused by S. pneumoniae. Can cause disorientation, confusion, somulence • Endocarditis can develop when organisms invade endocardium and valves

Pneumonia • Diagnostic Studies – X-ray – History – Physical examination – Gram stain of sputum – Transtracheal aspiration and bronchoscopy – Blood culture – ABG reveals hypoxia (shift to the left) – WBC increased greater than 15, 000

Pneumonia • Drug therapy – Empirical treatment – Macrolides – Erythromycin – Tetracycline not effective against pneumococcus – Modifications based on culture results and clinical response

Pneumonia • Collaborative Care – Appropriate antibiotic therapy – Increased fluid intake – Limited activity and rest – Antipyretics – Analgesics – Oxygen therapy

Pleural Effusion • Presence of fluid in the pleural space • Source is usually blood vessels or lymphatic vessels, abscess or other lesion that drains into the pleural space so rarely a primary disease process • Can only have up to 15 mls (lubricant fluid) occupying space • Atelectasis

Pleural Effusion • Could be complication of: – heart failure – Tuberculosis – Pneumonia – Pulmonary infections (viral especially) – Nephrotic syndrome – Pancreatitis – Connective tissue disease – Pulmonary embolism – Neoplastic tumors

Pleural Effusion • Effusion fluid could be clear (transudate or exudate), bloody or purulent • Formation or altered reabsorption • Symptoms manifested from original disease process – Pneumonia-fever, chills, Pleuritic chest pain – Malignancy-dyspnea, coughing

Pleural Effusion • Dyspnea • Compression atelectasis with impaired ventilation displaces mediastinal contents • Mediastinal shift occurs with large effusions • Pleural pain – inflammed • Pleural friction rub over effusion

Pleural Effusion • Medical management – Treat underlying cause – Prevent re-accumulation of fluid – Relieve discomfort – Relieve dyspnea – Prevent respiratory compromise – Treatment-thoracentesis – Pleurodesis (Bleomycin or Talc)

Pleural Effusion • Nursing Management – Implementing the medical regimen – Thoracentesis positioning – Pain management – Positioning – Facilitate drainage – Monitoring drainage system – Education of patient and family

Empyema Infected pleural effusion Pus in the pleural space Complication of respiratory infection Develops when the pulmonary lymphatics become blocked, leading to outpouring of contaminated lymphatics fluid into the pleural space • Thoracic surgery • •

Empyema • Clinical manifestations – Looks toxic – Cyanosis – Fever – Tachycardia – Cough – Pleural pain – Decrease breath sounds over area

Empyema • Diagnosis – Chest X-ray – Thoracentesis – Positive cultures from fluids

Empyema • Treatment – Antibiotics – Thracentesis – Chest tube with continuous drainage – Surgical debridement • Nursing Care – Chest tube management – Pain management – Education of patient and the family

Abscess Formation and Cavitation • Follows consolidation in which inflammation • Causes alveoli to fill with fluid, pus, and microorganisms • Necrosis (death/decay) of consolidated tissue may progress to bronchus cavitation

Abscess Formation and Cavitation • Cavitation – Abcess communication with a bronchus causes severe cough, copious foulsmelling sputum • Fever, chills, cough, sputum production, pleural pain, hemoptysis

Abscess Formation and Cavitation • Treatment – Antibiotics – Chest PT – Postural drainage – Bronchoscopy to drain abscess – Pretty high mortality

Pulmonary Edema • Abnormal accumulation of fluid IN the lung tissue and / or the alveolar space • Severe, life-threatening condition • Most commonly caused by increased microvascular pressure from abnormal cardiac function • Back up of blood into pulmonary vasculature • Fluid leaks out of the vasculature and into the interstitial space and the alveoli • “flash” pulmonary edema – rapid onset usually from sudden cardiac event (Myocardial Infarction)

Pulmonary Edema • Clinical Manifestations – Respiratory distress • Dyspnea • Air hunger • Central cyanosis • Anxiety and agitation • Coughing, foamy / frothy sputum or bloodtinged secretions • Confusion or stuporous

Pulmonary Edema • Medical Management – Correcting underlying disorders – Improving left ventricular function • Vasodilators • Inotropic medications • Afterload or preload agents • Contractility medications • IABP • Diuretics (especially for Flash Pulm. Edema) • OXYGEN!!!! To correct hypoxemia • MSO 4 reduces anxiety and pain

Pulmonary Edema • Administering oxygen, intubation and mechanical ventilation • Administer medications

Spontaneous Pneumothorax • • Occurs unexpectedly in healthy individuals Usually men 20 -40 years Rupture of Blebs (blister-like formations) – Pleurodesis • Caustic substances (talc) into pleural space causes intense inflammatory responds locally, scarring and adhesions occur

Acute Respiratory Failure • Sudden and life-threatening deterioration of the gas exchange function of the lung • Cannot keep up with the rate of oxygen consumption and CO 2 production • When Pa. O 2<50 mm. Hg (hypoxemia) • Pa. CO 2>50 mm. Hg (hypercapnia) • p. H < 7. 35 • Ventilation or perfusion impaired

Acute Respiratory Failure • Leading to ARF are: – Alveolar hypoventilation – Diffusion abnormalities – Ventilation-perfusion mismatching – Shunting

Acute Respiratory Failure • Common causes: – Decreased respiratory drive • Brain problems such as injury, MS, sedative use • Hypothyroidism – Dysfunction of the Chest wall • Diseases or disorders of the spinal cord, muscles, nerves, musculoskeletal, neuromuscular junction disorders –G-B Syndrome –ALS

Acute Respiratory Failure • Common causes: (continued) – Dysfunction of Lung parenchyma • Pleural effusion, pneumothorax, upper airway obstruction • Any condition which prevents expansion of lung • Pneumonia, Status asthmaticus, atelectasis, PE, Pulmonary edema – Other causes • Anesthetic drugs • Sedatives • Pain • Thoracic surgery

Acute Respiratory Failure • Clinical manifestations – Restlessness – Fatigue – Headache – Dyspnea – Air hunger – Tachycardia – Increased BP • As progresses – Confusion – Lethargy – Tachycardia – Tachypnea – Central cyanosis – Diaphoresis – Respiratory arrest

Acute Respiratory Failure • Medical management –Correct underlying cause –Intubation –Mechanical ventilation

Acute Respiratory Failure • Nursing management – Assisting with intubation – Maintain mechanical ventilation – Assess respiratory status with constant monitoring – Vital signs frequently – Turning – Oral care (with tube) – Education

Acute Respiratory Distress Syndrome (ARDS) • • Occurs with lung inflammation Diffuse alveolocapillary injury Sepsis multiple trauma Pneumonia Burns Aspiration Cardiopulmonary bypass surgery • • • Pancreatitis Blood transfusion Drug overdose Smoke Noxious gas inhalation Oxygen toxicity Radiation therapy DIC Highly acidic

ARDS

ARDS • Pathophysiology – Inflammatory mediators plays key roles in lung injury – Neutrophils, complement, endotoxin tumor necrosis factor (TNF) – Initial injury – Damage of capillary endothelium

ARDS • • Platelet aggregation Thrombus formation Neutrophils into area Endotoxin TNF Interleukin 1 These mediators cause extensive damage of the alveolocapillary membrane- permeability

ARDS • Increased capillary permeability • Allows fluids, proteins, and blood cells to leak from capillary bed into pulmonary interstitum and alveoli • Resulting pulmonary edema and hemorrhage • Surfactant is inactivated • collapse

Pathophysiology of ARDS

ARDS • Clinical Manifestations – Rapid, shallow breathing – Respiratory alkalosis – Marked dyspnea – Decreased lung compliance – Hypoxemia unresponsive to Oxygen (refractory hypoxemia) – Diffuse alveoli infiltration on CXR

ARDS • • • Evidence of cardiac disease Diffuse crackles Respiratory acidosis develops Further hypoxemia Hypotension Decreased C. O. and death

ARDS treatment – Supportive care – Mechanical ventilation with PEEP – High-oxygen concentrations – Sedation – Pharmacology Therapy • Interleukin -1 receptor antagonist • Neutrophil inhibitors • Pulmonary-specific vasodilators • Surfactant replacement therapy • Antisepsis agents • Antioxidant therapy • Corticosteroids – Nutritional Therapy • 35 -45 kcal/kg per day (enteral feeding)

Nursing Considerations of ARDS • ICU nursing – Continual close monitoring – Mechanical ventilation – Nebulizer treatments – Endotracheal suctioning – Chest physiotherapy – Multiple advanced procedures

Mechanical Ventilation • Improves oxygenation and ventilation • Decreases amount of oxygen demand work for effective breathing • Provides respiratory support until lung function is adequate • Indications – Hypoxemia, hypoventilation – Respiratory support s/p surgery – Drug overdose, trauma

Mechanical Ventilation: Management • Endotracheal intubation: ET tube – Short term airway – Requires tracheostomy for artificial airway longer than 10 -14 days – Goal • Maintain a patent airway • Reduce work of breathing • Means to remove secretions • Provide ventilation and oxygenation

Mechanical Ventilation: Intubation • Preparing for intubation – Oxygenation – Hemodynamic monitoring • Verifying placement – CO 2 concentration – Breath sounds – CXR • Stabilizing tube • Nursing care (Chart: 25 -7) – Maintain airway – Assessment

Tracheostomy • Surgical incision into the trachea for the purpose of establishing an airway • Preoperative teaching – Self care of airway – Methods of communication – Suctioning – Pain control – Ventilation/oxygenation support – Nutritional support

Tracheostomy: Post-op care • ABC’s • Recovery from anesthesia • Assess for complications • Tube obstruction Tube dislodgment Accidental decannulation Pneumothorax Subcutaneous emphysema Bleeding Infection

Tracheostomy: Care • Prevention of tissue damage – Stoma site – Cuff pressure • Humidification • Suctioning – Hypoxia, tissue trauma, infection, bronchospasm • Trach care • • • Bronchial/oral hygiene Nutrition Communication Psychological needs Weaning

Types of Mechanical Ventilators • • • Negative pressure Positive pressure Pressure-cycled: (infrequently used) Time-cycled: neonates, pediatrics Volume-cycled (common) Noninvasive positive pressure

Modes of Ventilation • Controlled ventilation: least used • Assist-control ventilation: most common • Synchronized intermittent mandatory ventilation (SIMV) • Maximum mandatory ventilation (MMV) • Positive end expiratory ventilation (PEEP) • Continuous positive airway pressure (CPAP)

Ventilator Controls and Settings To be covered in Simulation Lab Tidal volume (Vt): 10 -15 m. L/kg Rate or breaths/min: 12 -16/min Fraction of inspired air (FIO 2): Sighs: 6 -10/ min Peak airway (inspiratory) pressure (PIP) Continuous positive airway pressure (CPAP): 515 cm H 20 • Positive end-expiratory pressure (PEEP): 5 -15 cm H 20 • Flow: 40 L/min • • •

Ventilator: Management • • Patient first, ventilator second Ongoing assessment Promote psychological well-being Anticipate needs Patient safety Suctioning, positioning Prevent complications

Ventilator: Management (Cont) • Pharmacological management – Bronchodilators – Anti-inflammatory – Analgesics – Sedatives – Neuromuscular blocking drugs (Guitterrez: pg. 240)

Complications of Mechanical Ventilation • Cardiac • GI and nutritional – 1. Hypotension – 1. Stress ulcers – 2. Fluid – 2. Paralytic ileus retention – 3. Malnutrition • Lung – 4. Carbohydrates increase CO 2 production – 1. Barotrauma – 5. Electrolyte imbalance – 2. Volutrauma • Infection – 3. Acid-base abnormalities • Weaning/ extubation

Chest Tumors • Benign or malignant • Malignant is primary, arising from lung tissue, chest wall, or mediastinum • Could be a metastasis from another primary elsewhere

Chest Tumors • Leading cause of cancer death in the U. S. • Long term survival rate is low • Carcinoma tends to arise at sites of previous scarring (TB, fibrosis)

Chest Tumors • Factors – Tobacco – Second-hand smoke – Environmental exposure – Occupational exposure – Genetics – Dietary factors (fact that smokers don’t eat fruits or veggies!)

Chest Tumors • Clinical Manifestations – Develops insidiously, asymptomatic until late – S/S depend on location, degree of obstruction and presence of metastases – Cough or change in chronic cough – “smoker’s mythology-thought process

Chest Tumors Wheezing Dyspnea Hemoptysis or blood-tinged sputum Recurring fever Unresolved URI Chest pain (late manifestation) Tumor spread- CP and tightness, dysphagia, head or neck edema • Metastases brings lymph node involvement, brain, bone, adrenal gland, liver and contralateral lung • •

Chest Tumors • Assessment – Chest X-ray – CT scans – Sputum cytology – Bronchoscopy – Needle-aspiration – PET scans – Pulmonary function tests

Chest Tumors • Medical management – Depends on cell type, stage and physiologic status – Surgery – Radiation – Chemotherapy – Gene therapy

Chest Tumors • Surgical Management – Surgical resection • Lobectomy- single lobe • Bilobectomy-2 lobes • Sleeve resection- lobe and segment of bronchus • Pneumonectomy- entire lung • Segmentectomy- segment • Wedge resection-pie shaped area • Chest wall resection

Chest Tumors • Radiation – May cure small percentage – Relieve pressure – Control symptoms – Prophylactic irradiation to brain – Nursing care- monitor nutritional status, esophagitis, pneumonitis, fibrosis, – Psychological outlook, fatigue, anemia and infection

Chest Tumors • Chemotherapy – Used to alter tumor growth – Treat distant metastases – Alkylating agents – Platinum analogues – Taxanes – Vinca alkaloids – Doxorubicin – Gemcitabine – Vinorelbine – CPT-11 or VP-16

Chest Tumors • Palliative Care – Radiation to shrink tumor, pain relief – Hospice care for comfort and dignified end-of-life care

Chest Tumors • Treatment-related complications – Diminished pulmonary function – Pulmonary fibrosis – Pericarditis – Myelitis – Cor pulmonale – Complications of chemotherapy – Complications of mechanical ventilation

Chest Tumors • Managing symptoms – Relieving Nausea and vomiting and anorexia – Relieving breathing problems – Reducing fatigue

Chest Tumors • Tumors of the mediastinum – Neurogenic tumors, thymus, lymphomas – Cough, wheeze, dyspnea, superior vena caval syndrome – Swelling of neck and head – Weight loss – Invasion of the esophagus

Tumors of the mediastinum • Assessment and diagnostic Findings – Chest X-ray – CT scans – MRI – PET scan • Management – Surgical

Pulmonary Fibrosis • Excessive amount of fibrous connective tissue in the lung • Scar formation after active TB, ARDS or inhalation • Idiopathic • Causes marked loss of lung compliance • Lung becomes stiff, difficult to ventilate • Decreases diffusing capacity • Causes hypoxemia, diffuse pulmonary fibrosispoor prognosis

Pulmonary Fibrosis • Chest wall restriction – Deformed immobile – Obesity – Kyphoscoliosis – Neuromuscular disease • Dyspneic • Susceptible to LRT infections • hypoventilation

Chest Tubes • To be covered in Simulation Lab but…. . • Thoracentesis to remove 1200 cc of Plural Fluid • Chest tube in a rural setting • Empyema • Pulmonary embolism • ARDS • Cardiac tamponade