Chapter 32
Care of Patients with Noninfectious Lower
Respiratory Problems
Mrs. Marion Kreisel MSN, RN
NU230 Adult Health 2
Fall 2011
Chronic Airflow Limitation
• Chronic airflow limitation includes the
chronic lung diseases:
• Asthma
• Chronic bronchitis
• Pulmonary emphysema
Chronic Airflow Limitation
Chronic Obstructive Pulmonary
Disease (COPD)
• COPD includes:
• Emphysema
• Chronic Bronchitis
• Characterized by bronchospasm and
dyspnea
• Tissue damage is not reversible and
increases in severity, eventually leading to
respiratory failure
Asthma
• Intermittent disease
• Reversible airflow obstruction and
wheezing
Asthma: Pathophysiology
• Bronchial asthma is an intermittent and reversible
airflow obstruction affecting only the airways, not
the alveoli
• Airway obstruction occurs by:
• Inflammation
• Airway hyperresponsiveness
Asthma: Etiology
• Classified into different types based on triggering
events
• Inflammation occurs in response to specific
allergens, general irritants, microorganisms, and
aspirin
• Hyperresponsiveness occurs with exercise, URI,
or unknown reasons
Asthma: Special Considerations
• Older Adults:
• Teach how to prevent asthma attacks
• Women:
• 35% higher incidence in women than men
• Teach correct use of preventive and rescue
drugs
Collaborative Management
• Assessment:
• History
• Physical assessment and clinical
manifestations:
• Audible wheeze and increased
respiratory rate
• Increased cough
• Use of accessory muscles
• ”Barrel chest” from air trapping
• Long breathing cycle
• Cyanosis
• Hypoxemia
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
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 flow rate (PEFR)
• Residual Volume (RV) is increased
Interventions
• Patient education: asthma is often an
intermittent disease; with guided self-care,
patients can co-manage this disease,
increasing symptom-free periods and
decreasing the number and severity of
attacks
• Peak flow meter should be used twice
daily by the patient if in red zone
administer rescue drugs STAT!
• Personal drug therapy plan
Asthma: Drug Therapy
• Pharmacologic management is based on
the step category for severity and
treatment
• Preventive therapy drugs:
• Used to change the airway
responsiveness to prevent asthma
attacks
• Used every day, regardless of
symptoms
• Rescue drugs are used to actually stop an
attack once it has started
Asthma: Drug Therapy
• Bronchodilators:
• Short-acting beta2 agonists: rapid bronchodilation but short
term relief (Proventil, Albuteral, Ventolin, Xopenex)
• Long-acting beta2 agonists: slow bronchodilation with long term
relief (Serevent & Foradil)
Beta 2 agonists bind to the beta 2 adrenergic receptors &
cause an increase in the intracellular level of Cyclic
Adenosine Monophosphate (cAMP) This substance
triggers smooth muscle relaxation
Asthma: Drug Therapy Cont:
• Cholinergic antagonists: Purpose to both rescue & prevent
asthma attacks (Atrovent & Spiriva)
Cholinergic antagonists also known as Anticholinergic drugs
block the parasympathetic nervous system resulting in
increased bronchodilation and decreased pulmonary
secreations.
• Methylxanthines: Used when other types of management are
ineffective.
• Need to monitor drug levels
• High side effects
• Example of Drugs: Theodur (theophylline), (oxtriphylline),
Choledyl
Asthma: Drug Therapy (Cont’d)
• Anti-Inflammatory agents: decrease the inflammatory
response in the airways. Can be given systemically or
inhaled.
• Corticosteroids: decrease inflammatory & immune
response (Flovent:Fluticasone, Pulmicort:Budesonide,
Asmanex: mometasone)
• NSAIDs: inhaled or taken orally used to prevent asthma
attacks taken on a regular basis. They are have different
mechanisms of action (Nedocromil:Tilade, Cromolyn
Sodium:Intal NOT USED AS A RESCUE DRUG
• Leukotriene antagonists: Oral drugs work to prevent
attacks: Singulair: Montelukast, Accolate:Zafirlukast
• Immunodulators
Other Treatments for Asthma
• Exercise and activity is recommended to promote ventilation
and perfusion
• Oxygen therapy is delivered via mask, nasal cannula, or
endotracheal tube in acute asthma attack:
• Heliox can improve oxygen therapy
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 patient may develop
pneumothorax and cardiac or respiratory arrest
• Treatment: IV fluids, potent systemic bronchodilator,
steroids, epinephrine, and oxygen
Emphysema
• Two major changes: loss of lung elasticity
and hyperinflation of the lung
• Dyspnea and the need for an increased
respiratory rate
• Air trapping caused by loss of elastic recoil
in the alveolar walls, overstretching and
enlargement of the alveoli into bullae, and
collapse of small airways (bronchioles)
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
COPD: Etiology and Genetic Risk
• Cigarette smoking
• Air pollution
COPD: Complications
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Hypoxemia
Acidosis
Respiratory infections
Cardiac failure, especially cor pulmonale
Cardiac dysrhythmias
COPD: Physical Assessment and
Clinical Manifestations
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History
General appearance
Respiratory changes
Cardiac changes
Dyspnea Assessment Tool
Laboratory Assessment
• ABG values for abnormal oxygenation,
ventilation, and acid-base status
• Sputum samples
• CBC
• Hemoglobin and hematocrit blood tests
• Serum electrolyte levels
• Chest x-ray
• Pulmonary function test
Impaired Gas Exchange
• Nonsurgical interventions for chronic
obstructive pulmonary disease:
• Airway management
• Monitoring patient at least every 2
hours
• Cough enhancement
• Oxygen therapy
• Drug therapy
• Pulmonary rehabilitation
Drug Therapy
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Beta-adrenergic agents
Cholinergic antagonists
Methylxanthines
Corticosteroids
NSAIDs
Mucolytics
Surgical Management
• Lung transplantation for end-stage patients
• 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
• Assessment of patient for breathing
pattern and respiratory infection
• Interventions for the chronic obstructive
pulmonary disease patient:
• Specific breathing techniques
• Positioning to help alleviate dyspnea
• Energy conservation
Ineffective Airway Clearance
• Assessment of breath sounds
• Interventions for compromised breathing:
• Careful use of drugs
• Controlled coughing
• Chest physiotherapy with postural
drainage
• Suctioning
• Positioning
Ineffective Airway Clearance
(Cont’d)
• Hydration via beverage and humidifier
• Flutter-valve mucus clearance devices
• 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
• Dyspnea management
• Food selection to prevent weight loss
Anxiety
• Interventions for increased anxiety:
• Important to have patient understand
that anxiety will worsen symptoms
• Plan ways to deal with anxiety
Activity Intolerance
• Interventions to increase activity level:
• Encourage patient to pace activities
and promote self-care
• Do not rush through morning activities
• Gradually increase activity
• Use supplemental oxygen therapy
Potential for Pneumonia or Other
Respiratory Infections
• Risk is greater for older patients
• Interventions include:
• Avoidance of large crowds
• Pneumonia vaccination
• Yearly influenza vaccine
COPD: Community-Based Care
• Home care management:
• Long-term use of oxygen
• Pulmonary rehabilitation program
• Health teaching:
• Drug therapy
• Manifestations of infection
• Breathing techniques
• Relaxation therapy
Cystic Fibrosis
• Genetic disease affecting many organs,
lethally impairing pulmonary function
• Present from birth, first seen in early
childhood, although almost half of all
people with cystic fibrosis in the United
States are adults
• Error of chloride transport, producing thick
mucus with low water content
• Mucus plugs up glands, causing atrophy
and organ dysfunction
Cystic Fibrosis
Cystic Fibrosis: 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
Cystic Fibrosis: Pulmonary
Manifestations
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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
Cystic Fibrosis: Nonsurgical
Interventions
• Nutritional management:
• Weight maintenance
• Vitamin supplementation
• Diabetes management
• Pancreatic enzyme replacement
• Prevention/maintenance therapy:
• Chest physiotherapy
• Positive expiratory pressure
• Active cycle breathing technique
• Exercise
Cystic Fibrosis: Nonsurgical
Interventions (cont’d)
• Exacerbation therapy:
• Avoid mechanical ventilation
• Supplemental oxygen
• Heliox
• Airway clearance techniques
• Drug therapy
• Patient education on prevention of
exacerbation
Cystic Fibrosis: Surgical
Management
• Lung and/or pancreatic transplantation:
• Does not cure the disease, because the
genetic defect in chloride transport in
other tissues and the upper airways
remains
• Extends life by 10 to 20 years
• Patient is at continued risk for lethal
pulmonary infections
Primary Pulmonary
Hypertension (PPH)
• PPH occurs in the absence of other lung
disorders, and its cause is unknown
• 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
Pharmacologic Interventions
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Warfarin therapy
Calcium channel blockers
Endothelin-receptor antagonists
Natural and synthetic prostacyclin agents
Digoxin and diuretics
Oxygen therapy
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 is most common manifestation
Sarcoidosis
• Granulomatous disorder of unknown
cause that affects the lungs most often
• Autoimmune responses in which the
normally protective T-lymphocytes
increase and damage lung tissue
• Corticosteroids are the main type of
therapy
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 and
other immunosuppressants
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
• Prevention through special respirators and
adequate ventilation
Lung Cancer
• A leading cause of cancer deaths
worldwide
• Poor long-term survival because of latestage diagnosis
• Bronchogenic carcinomas
• Paraneoplastic syndromes
• Staged to assess size and extent of
disease
• Etiology and genetic risk
Lung Cancer (Cont’d)
• Health promotion and maintenance
• Assessment:
• History
• Pulmonary manifestations
• Nonpulmonary manifestations
• Psychosocial assessment
• Diagnostic assessment
Lung Cancer: Nonsurgical
Management
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Chemotherapy
Targeted therapy
Radiation therapy
Photodynamic therapy
Lung Cancer: Surgical
Management
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Lobectomy
Pneumonectomy
Segmentectomy
Wedge resection
Common Incision Locations for
Partial or Total Pneumonectomy
Chest Tube Placement
Chest Tube Chambers
• Chamber 1: collects the fluid draining from the patient
• Chamber 2: water seal that prevents air from entering the
patient’s pleural space
• Chamber 3: suction control of the system
Nursing Care After Thoracotomy
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Pain management
Respiratory management
Pneumonectomy care
Chest Tube Care: Make sure water is bubbling gently. If
not quickly and carefully reposition patient to see if
blockage is the reason. If this does not fix the problem
this is an emergency and lead to excessive pressure in
the chest.
• Have at the bedside always sterile occlusive gauze
and padded clamps incase tube becomes dislodged.
• Be very careful when milking tube, it can cause more
damage than good.
Interventions for Palliation
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Oxygen therapy
Drug therapy
Radiation therapy
Thoracentesis and pleurodesis
Dyspnea management
Pain management
Hospice care
NCLEX TIME
Question 1
Which ethnic group is typically known to have
the highest prevalence of smoking?
A.
B.
C.
D.
African Americans
Asians
Caucasians
American Indians
Question 2
Approximately what percentage of the adult
population in the United States smoke
cigarettes?
A.
B.
C.
D.
5%
10%
20%
30%
Question 3
Which correctly reflects the prevalence of
asthma when comparing the adult and
child populations in the United States?
The percentage of children who have
asthma is ________ than adults.
A. Higher than
B. Lower than
C. The same as
Question 4
Which risk factor is responsible for the
majority of deaths from lung cancer?
A.
B.
C.
D.
Cigarette smoking
Occupational radiation exposure
Chronic exposure to asbestos
Air pollution
Question 5
A patient with a history of asthma is having
shortness of breath. The nurse discovers
that the peak flowmeter indicates a peak
expiratory flow (PEF) reading that is in
the red zone. The nurse should immediately:
A. Repeat the PEF reading to verify the
results.
B. Take the patient’s vital signs.
C. Administer the rescue drugs.
D. Notify the patient’s prescriber.