Atelectasis
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Closure or collapse of alveoli.
Can be acute or chronic.
Can be micro or macroatelectasis.
Caused by reduced alveolar ventilation.
Insidious onset
S/s: Cough, Sputum, Low grade fever
Prevention – C&DB
Lower
Respiratory
Assessment
2 forms of atelectasis: (lung collapse)
a. When an obstruction prevents air from reaching the distal airways and therefore,
the alveoli collapse.
 The most frequent cause is blockage of a bronchus by a mucous or
mucopurulent (pus-filled) plug, as might occur postoperateively
b. When accumulations of fluid, blood, or air within the pleural cavity collapses the
lung.
 This can occur with CHF (when poor circulation leads to build up of fluid in
the pleural cavity)
 or because of leakage of air, caused by a pneumothorax.
Pneumonia
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Inflammation of the lung parenchyma caused by microbial agent.
Most common cause of death from infection in the U.S.
6th leading cause of death of all ages in the U.S.
Caused by various organisms – bacteria,
– Mycobacteria.
– Chlamydiae.
– Mycoplasma.
– Fungi.
– Parasites.
– Viruses.
Pneumonia causes:
- Obstruction of bronchioles
- Decreases gas exchange
- Increases exudates
- Symptoms include:
 Cough – productive
- greenish, yellow – streptococcal infection
- yellowish or blood streaked – staphylococcal infection
 Fever, Chills
 Tachycardia, Tachypnea, Dyspnea
 Pleural pain
 Malaise
 Repiratory distress
 Decrease breath sounds
Pneumonia
Methods of classifying pneumonia
1) Community acquired Pneumonia (CAP)
– Occurs in community setting or during 1st 48 hours of hospitalization
- Most Prevalent during winter & spring.
2) Hospital acquired pneumonia (HAP)
- Nosocomial = pneumonia occurring >48 hours after hospital admission
• HAP – caused by the Enterobactacter species, Escherichia coli, Klebsiella,
Proteus, & others.
• This infection occurs when:
– Host defenses are impaired.
– Organisms is introduced into pt’s lower respiratory tract & overwhelms
defense.
– Or a highly virulent organism is present.
3) Pneumonia in the immunocompromised host
- Patients with Pneumocystic carinii, lung cancer
4) Aspiration pneumonia
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Pneumonia
Inflammation occurs in alveoli and produces exudate that impairs gas exchange, leading
to hypoxia.
WBC’s attracted to this area fill spaces that normally contain air.
Bronchopneumonia – infection distributed in bronchi and surrounding lung parenchyma.
(Most common)
Lobar pneumonia – large part of lobe is affected
Pneumonia: Risk Factors
– More common with certain underlying diseases such as:
• CHF,
DM, Alcoholism, COPD, AIDS
What to do…
Preventing HAP Pneumonia
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Staff education & infection surveillance
Interrupt person to person/equipment transmission
Decrease host risk of infection
Pneumonia
Vaccination against pneumococcal infection for: People > 65 yrs.;
– Immunosupressed people; or for people living where risk is high.
Avoid vaccine during 1st trimester of pregnancy.
Pneumonia: Clinical manifestations
– Dullness with consolidation on percussion of chest
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Sudden onset of fever >100o
– Shaking chills with bacterial pneumonia
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Chest pain aggravated by hacking cough
Dyspnea, grunting, nasal flaring
Purulent sputum
Anxiety & confusion
In the elderly the only sign may be mental changes & dehydration
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Pneumonia: Diagnostic assessment
CXR shows density changes primarily in lower lung fields
Sputum culture positive for causative organism
WBC are elevated in bacterial pneumonia
WBC may be depressed in mycoplasmal or viral origin
Pneumonia: Medical management
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Appropriate antibiotic
Hydration
Antipyretics
Warm, moist mist inhalation
Antihistamines
O2
Pneumonia: Nursing management
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Removal of secretions
Increase fluids PO or IV (2 liters/day)
Humidify air
Deep breathing
Incentive spirometer
Chest percussion & postural drainage
Monitor pulse oximentry
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Rest - semi-fowlers
Nutrition: fluids with electrolytes
Monitor for complications
Observe for response to therapy
Should see improvement 24-48 hrs after
antibiotics started
- Observe for Complications: •Medication reaction •Superinfections •Shock
•Multisystem failure •Atelectasis, •Pleural effusion
– Patient teaching
Pulmonary Tuberculosis
Tuberculosis is an infectious disease caused by mycobacterium tuberculosis, an acid fast
bacillus that is airborne.
– May affect lungs, kidneys, bones, & lymph nodes.
Tuberculosis
– Definition: an infectious disease caused by mycobacterium tuberculosis, an acid fast
bacillus that is airborne.
– May affect lungs, kidneys, bones, & lymph nodes.
– Affects 1/3 worl’d population
– Leading cause of death from infectious diseases worldwide.
– Recent immigrants in the U.S. from 3rd world countries and the HIV epidemic have led
to the increase of TB since 1986.
Brief Exposures to TB Do Not Usually Result in Infection.
• Repeated, close contact with an infected individual is how most TB is spread.
• 2-6 wks after a primary infection sensitized t-cells cause a positive reaction to skin testing
• TB ioutside the lund is more difficult to diagnose.
• Treatment may take longer.
People at Risk Include:
• Elderly, plus infants & children under 15
• Native Americans, Eskimos, blacks, homeless, Asians & Hispanics.
• Alcoholics & drug abusers; and those with reduced immunity.
• Health care worker performing high risk activities
• Living in overcrowded, substandard housing
• Insitutionalization
• Emigration from countries with high prevalence
If TB Germ Gets Past Body’s Defences
• It becomes Infectious of walls itself off
• If Walls Itself off there are:
• No symptoms
• Tubercular bacilli forms a calcified lesion & encapsulates itself
• May or may not be seen on CXR
• Patient will have positive skin test; they can reactivate months / yrs later
• Approximately 10% of people that are initially infected will develop active disease.
Active TB
This material liquefies, drains, & is coughed up as sputum.
The remaining cavities are seen on CXR.
These areas can calcify and seal over with living TB organisms, remaining dormant for yrs.
When immunity decreases, these sealed over areas become reinfected
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Symptomatic Infection
4 - 12 wks incubation after tubercular bacilli exposure:
Seen on CXR
Chronic cough, Fatigue, Low grade fever, Weight loss, Night sweats, anorexia,
hymoptosis
Purulent sputum becoming blood tinged
TB
Without TX TB Progresses to Other Body Sites (Disseminated TB)
• Urinary tract
Bones
Meninges
• Genital tract
Peritoneium
Assessment for TB
• Hx of exposure or travel to high risk countries
• Sputum positive for AFB
• CXR - usually reveals lesions in the upper lobes.
• Culture is only method of confirming DX of TB
• Skin test - read with caution 48 – 72 hours after injection
Elderly consideration: they may have a delayed reaction to skin test up to 1 wk (recall
phenomenon). A 2nd skin test is performed in 1-2 weeks. However, a negative skin test
does not exclude TB infection.
TB Skin Test
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A reaction occurs when both induration (hardening) and erythema are noted.
Diameter of induration is measured in millimeters.
0 – 4 mm considered not significant.
5 mm or > may be significant.
> 10 mm is considered significant.
A significant reaction indicates that the patient has been exposed to TB recently, in the
past or has been vaccinated with BCG
Medical Management p. 647
• Preventive measures - 300 mg isoniazed qd for 6 - 12 months. Recommended for:
1) Newly infected pts (have converted TB skin test but no other signs of infection).
2) Those living with or closely associated with someone with active TB.
3) Vitamin B6 (pyridoxine) administered with INH to prevent peripheral neuropathy
4) Rifampin can increase metabolism of beta blockers, digoxin, oral anticoagulants,
contraceptives, oral hypoglycemic agents and others.
Isoniazad (INH)
Pyrazinamide
Rifampin
Ethambutol
Rifamputin
Combo: INH + Rifampin (Rifamate)
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Therapeutic Measures:
Persons with active TB are started on 4 or more drugs to help prevent drug resistive
organisms.
Doses may be large because TB is difficult to kill.
Long-term uninterrupted therapy is important.
See pg. 647 B/S for meds.
Care of Hospitalized Pt
• Done in private room with fresh circulating air – negative pressure
• After tx started & pt able to provide 3 neg sputums for AFB, pt considered noncontiguous
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(about 2 wks).
Nursing care is directed toward follow up.
Monitoring & assessing med compliance &side effects.
Monitoring disease process,
Collecting specimens for AFB.
Patient Teaching:
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Take anti TB drugs as prescribed.
Drugs are always taken in combination of 2, 3 or 4.
Drugs must be taken uninterruptedly.
Cover nose and mouth with tissue when coughing, sneezing or laughing.
Place used tissue in bag which is to be burned.
Pleural Effusion
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A collection of fluid in the pleural space usually secondary to another disease.
Can be complication of CHF, TB, pneumonia, pulmonary infections & other conditions.
Often caused by underlying disease.
Fever, chills, pleuritic chest pain from pneumonia.
Dyspnea & cough from malignant tumor.
Size of effusion & pt condition determine severity of symptoms.
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Pleural Effusion: Assessment
Decreased or absent breath sounds
Dull, flat sound on percussion
May have respiratory distress and deviated trach
Confirmed thru CXR, CT scan & thoracentesis
Pleural Pleural fluid analyzed by:
– Cultures, Gram’s stain, AFB, Blood count, Chemistry panel, Cytologic studies.
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Pleural Effusion: Medical Mngmt
Treat underlying cause; Relieve discomfort and dyspnea; Thoracentesis or chest tube.
Chronic Obstructive Pulmonary Disease
• COPD & chronic obstructive lung disease (COLD) are terms referring to several disorders
affecting movement of air into and out of lungs.
• Includes: Bronchitis, Emphysema, & Asthma – (which is now considered a separate
disorder).
• COPD & chronic obstructive lung disease (COLD) are terms referring to several disorders
affecting movement of air into and out of lungs.
• 4th leading cause of death in the US.
• Includes: Bronchitis; Emphysema; Asthma
• These Clients Have An:
1. Increase in # of Goblet Cells Resulting in
more Mucus.
2. Impaired ciliary Function.
• These problem increase susceptibility to infection.
• When infection occurs mucus production is even greater.
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This results in reduced alveolar ventilation and abnormal V/Q Ratio.
Ø < Pao2 ;
> Paco2
Ø Polycythemia develops to compensate for hypoxemia.
• Etiology/risk Factors of COPD
1. Smoking (causes excess mucus production, coughing, destruction of ciliary
function, inflammation and damaged bronchiolar and alveolar walls.)
2. Chronic respiratory infections
3. Aging process
4. Genetic Component
COPD: Clinical manifestations
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Dyspnea, Cough, labored breathing
Weight loss
At risk for respiratory infections
Complications
• Respiratory insufficiency and failure
• Pneumonia; Atelectasis; Pneumothorax
COPD: Medical mgmnt
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Inhaled bronchodilators
– On regular schedule or PRN
– Prophylactically or during flare-up of illness
– O2 therapy for pt’s with paO2 of less than 55mm hg & is associated /W reduction in
mortality rate
BRONCHITIS
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Definition: chronic inflammation of the bronchi with mucous production and chronic
cough.
Chronic bronchitis initially affects only the large bronchi but eventually all airways are
involved.
Airways become obstructed and collapse and air is trapped in the distal portion
BRONCHIECTASIS
• Chronic, irreversible dilation of the bronchi.
• Occurs from pulmonary infections & obstructions of the bronchus; aspiration of foreign
bodies (emesis) or other pressure from tumors, dilated blood vessels & enlarged lymph
nodes.
• The inflammatory process damages the bronchial wall, causing loss of support & thick
sputum that obstructs the bronchi.
• The walls become permanently distended and distorted.
• The distal alveoli collapse. Scarring or fibrosis replaces lung tissue with decreased
ventilation.
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Bronchiectasis: Clinical manifestations
Chronic cough; Hemoptysis; Clubbing of fingers
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Large amounts of purulent sputum
Repeated pulmonary infections
Assessment
• Prolonged history of productive cough
• CT scan
Bronchiectasis: Medical Management
• Promote bronchial drainage
• Chest PT & postural drainage
• Stop smoking.
• Prevent & control infection thru antibiotics
• Vaccinate against influenza & pneumococcal pneumonia.
• Bronchodilators
Surgical Management: the diseased tissue is removed
Emphysema
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Destruction of alveoli, partial airway collapse & loss of elastic recoil result in over
distention and difficult expiration.
The pulmonary blood vessels are reduced as the alveolar continue to
break down.
Pulmonary blood flow is increased and the right ventricle is forced to maintain a higher
B/P in the pulmonary artery. This results in right sided heart failure (cor pulmonale)
• Respiration becomes a conscious effort.
Chronic hyperinflation of the lungs results in
“barrel chest”
Emphysema: S/Sx’s
• Often have long history of smoking
• Productive cough; SOB, Wheezing; Decreased exercise tolerance
• Age related: usually past 50 years of age
• These problems contribute to weight loss, weakness & inactivity.
Emphysema - Treatment
• Bronchodilators
- Antibiotics
• Antihistamines
- Expectorants
• Steroids
- Mast cell stabilizers
• Use narcotics, tranquilizers and sedatives with caution as they depress respiratory
center.
• Give O2 when severe exertional or resting hypoxemia (paO2 <40mm hg) 1 – 3 L/min to
increase O2 to 60 – 80.
• Resp center is triggered by low O2 in these individuals.
• Clear Secretions; postural drainage; CXR
• Nebulized bronchodilator
• Exercise Can Help Enhance Cardiovascular Fitness; BUT avoid High Altitudes
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Adequate Nutrition - frequent, small meals
Evaluate Mental Status
- Pursed Lip Breathing
Asthma
• Asthma Definition- a chronic inflammatory disease causing hyper-responsiveness,
muscosal edema & mucus production.
• Affects 3—4% of U.S. Population.
• Asthma Definition- A chronic inflammatory disease causing hyperresponsiveness of the
airways, muscosal edema & mucus production.
• Affects 3—4% of U.S. Population.
Etiology
• Inherited
• Affected by environmental factors (viral infections, allergens, pollutants)
• Other factors include:
– Stress, exercise, strong odors.
Pathophysiology
• Chronic inflammatory process producing: mucosal edema, mucus secretions
& airway inflammation.
Allergens include: dust, pollen, mold, smoke, medication, food, respiratory infections
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Asthma - Symptoms
Mild episode – wheeze, cough, chest tightness, SOB, occurs with activity.
Moderate episode – wheeze, cough, chest tightness, SOB, while at rest. May interfere
with daily activity.
Severe episode – severe shortness of breath, wheeze (may disappear with very severe
episode), cough, & chest tightness at rest. Difficulty walking and talking.
Asthma: Assessment
Dyspnea; wheezing, especially on Expiration
If unable to auscultation wheezing during asthma attack: it may mean that small airways
are too constricted to allow any airflow.
Bronchospasm - may lead to continuous coughing in attempt to clear airways
Low O2 Sat
Marked Respiratory Effort, Tachycardia
Pronlonged Expiration
Nonproductive Cough
Asthma
Complications - (Life Threatening.)
• Bronchospasms Intensify.
• Loabaored breathing increases 5-10 times
• Pneumothorax can develop
• Can lead to respiratory or cardiac arrest
Asthma Diagnostic Assessment
• Spirometry / Pulmonary Function Tests Shows Decreased Expiratory Air Flow
• ABG’s = Hypoxemia and Respiratory Alkalosis
- Breath Sounds Reveal Wheezing
• High eosinophil Count (CBC)
- Skin Testing to Identify Specific Allergens
Asthma: Medical Management
Prevention –
• avoid allergens or environmental triggers (remove carpets, pets, control dust, etc.)
• •Bronchodilators can be used to TX or prevent asthma
– Epinephrine
- Terbutaline (Brethine)
– Isuprel
- Bronkosol
– Alupent
- Albuterol
Asthma: Medical Management
• IV theophylline - smooth muscle relaxant
• IV steroids - prevent mast cell from emptying
• If these TX don’t work admit to hospital.
• May need ET tube and mechanical ventilation
• Nsaid’s
• Inhalers: (intal, nasalcrom) - prevent asthma attacks by stabilizing mast cell and
preventing release of histamine
Pulmonary Edema
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An abnormal accumulation of fluid in the lung tissue &/or alveolar space.
This causes increased pressure in the microblood vessels in the lungs which causes fluid
to leak into the interstitial space and the alveoli.
This is caused by abnormal cardiac functioning.
Hypervolumemia. Too much volume
When one lung has been removed all the cardiac output than goes to the remaining lung.
Pulmonary Edema - Manifestations
Respiratory distress - Dyspnea & Air hunger
Cyanosis of lips and nails; Pt becomes anxious
Foam or froth is spit up or suctioned out of airway
Pulmonary Edema - Assessment
Crackles; CXR reveals increased interstitial markings
Pulse oximetry values fall; ABG’s indicate hypoxemia
Pulmonary Edema - Medical Management
• Focus on underlying cause
• Improve left ventricular function: c Vasodilators & Inotropic medications
• Morphine; Diuretics; Fluid restrictions; Oxygen ; Intubate ventilate
Acute Respiratory Failure
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Sudden, life threatening deterioration of gas exchange in the lungs
Defined as: PaO2 to less than 50 mmHg
– PaCO2 greater than 50 mm Hg
– ph less than 7.35
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Ventilation/perfusion mechanisms in the lung are impaired. Some causes are
– Alveolar hypoventilation
– Diffusion abnormalities
– Ventilation-perfusion mismatching
– Shunting
Acute Respiratory Failure – Clinical Manifestations
• Restlessness
• As hypoxemia progresses
– Confusion
• Fatigue
– Lethargy
• Headache
– Tachycardia
• Dyspnea
– Tachypnea
• Air hunger
– Central cyanosis
• Tachycardia
– Diaphoresis
• Increased blood pressure
– Respiratory arrest
– Use of accessory muscles
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Decreased breath sounds