Lower Respiratory Disorders Part 1

8/3/2019 Lower Respiratory Disorders Part 1

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Joseph Krafft MSN APN-BC CCRN


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If two areas of different pressure communicate,gas will move from the area of higher pressureto the area of lower pressure

This movement of air causes wind when ahigh pressure system is near a low pressuresystem in the atmosphere


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Brain signals thephrenic nerve

Phrenic nerve

stimulates thediaphragm (muscle) tocontract

When diaphragmcontracts, it movesdown, making thethoracic cavity larger


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When the diaphragmcontracts, it moves down,increasing the volume ofthe thoracic cavity When

the volume increases, thepressureinside decreases Air moves from an area of

higher pressure, theatmosphere,to an area of

lower pressure, the lungs Pressure within the lungs

is called intrapulmonarypressure


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Exhalation occurs whenthe phrenic nervestimulus stops

The diaphragm relaxesand moves up in the chest

This reduces the volumeof the thoracic cavity

When volume decreases,intrapulmonary pressure

increases Air flows out of the lungs

to the lower atmosphericpressure


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Remember, this is normally an unconsciousprocess

Lungs naturally recoil, so exhalation

restores the lungs to their resting position However, in respiratory distress, particularly

with airway obstruction, exhalation cancreate increased work of breathing as the

abdominal muscles try to force air out ofthe lungs


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Hypoxia : Decreased levels of oxygen in the tissues Hypoxemia : Decreased levels of oxygen in arterial

blood

Hypercapnia: Increased levels of CO2

in the blood

Hypocapnia : Decreased levels of CO2 in the blood Dyspnea : Difficulty breathing Tachypnea : Rapid rate of breathing Cyanosis : Bluish discoloration of skin and mucous

membranes due to poor oxygenation of the blood

Hemoptysis : Blood in the sputum


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Atelectasis is caused by a blockage of the airpassages (bronchus or bronchioles) or bypressure on the outside of the lung.

Depending on the severity of the atelectasis,there may be no obvious signs or symptoms.If you do experience signs and symptoms,

they may include:


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Breathing difficulty Chest pain

Cough


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Anesthesia Foreign object in the airway (most common in

children)

Lung diseases

Mucus that plugs the airway Pressure on the lung caused by buildup of fluid

between the ribs and the lungs

Prolonged bed rest with few changes in position

Shallow breathing Tumors that obstruct the airway may lead to

atelectasis


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Inspection cough

delayed chest expansion on the affected side

increased respiratory rate increased pulse

possible cyanosis


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Palpation chest expansion decreased on the affected

side

tactile fremitus decreased or absent over theinvolved area

with a large collapse, the trachea may deviateor shift toward the affected area


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Auscultation breath sounds decreased or absent over

involved area

no adventitious sounds if bronchus isobstructed

occasional fine crackles if bronchus is patent


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Deep Breathing andCoughing

Incentive Spirometry


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Impaired gas exchange

Ineffective airway clearance

Ineffective breathing pattern


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Inflammation of the lung parenchyma 6th Leading Cause of Death in USA.

Incidence and mortality highest among olderadults and people with debilitating diseases.

Presents as infectious or noninfectious.

Classified as Community-Acquired,Nosocomial, or Opportunistic.

Streptococcus pneumoniae implicated in 75%of all cases.


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Lower Respiratory Tract should be sterile.

Most common mode of entry is aspiration oforopharyngeal secretions containing infectious

microbes. Contaminated water, droplet transmission, and

septicemic transmissions can also occur.

Microorganism colonization of the alveoli results

in antigen-antibody release, resulting ininflammation, edema, and exudate accumulation,which infiltrates and obstructs airway flow.


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Acute Bacterial: Typically results from Strept. pneumoniae.

Spread via person-to-person contact, inhaled viathe individuals own airway, or droplet.

Results in alveolar edema and infiltration withexudate.

Consolidation occurs from alveolar and bronchialfilling with blood cells, fibrin, and bacteria.

Lower Lobes (Lobar Pneumonia) most commonlyaffected


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Manifests as highly acute, rapid onset of chills,fever, and cough (rust or purulent expectorant).

Pleuritic (sharp) CP w/ breathing is typical.

Lung Sounds are diminished w/ crackles.

Dyspnea and cyanosis noted in gas exchangeimpairment.

Bronchopneumonia presents with a low-gradefever, cough, and scattered cracklesless acutein presentation.

In the older adult, S/S may be different becauseof altered immune capabilities: S/S of hypoxiaare common.


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Causative organism mycoplasma pneumoniae Develop patchy inflammatory changes in the

alveoli

Young adults primary affected population

Highly contagious

S&S: fever,H/A, myalgias, arthralgias, cough

Referred to as Walking Pneumonia


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Form of bronchopneumonia caused by Legionella pneumophilia- found in (warm, long-standing) water.

1st recognized after spreading rapidly at the 1976 AmericanLegion Convention.

Smokers, older adults, and people with chronic diseases are

most susceptible. Manifests as dry cough, dyspnea, general malaise,

chills/fever, HA, confusion, anorexia and diarrhea.

Consolidation is patchy or lobar.

Mortality rate is 31% in non-immunocompetent; 81% ifimmunocompromised.


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Influenza and adenovirus most commonorganisms

Lung involvement is limited to the alveoliseptum and interstitial spaces

Occurs in community epidemics

S&S: Flu like sx, H/A, fever, fatigue, malaiseand muscle aching


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Occurs in 75-80% of people with AIDS Produces patchy involvement throughout the

lungs causing alveoli to thicken, becomeedematous and fill with foamy protein rich

fluid

Abrupt onset with fever, tachypnea, and SOB


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Chemical and bacterial pneumonia fromaspiration of gastric contents into the lungs

Risk factors: emergency surgery, obstetricprocedures, depressed cough and gag reflex,impaired swallowing, enteral nutrition


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Sputum Gram Stain Sputum C&S: Ensure Lower Airway Sample

Not Oropharyngeal

WBC (>10,000 = Infection)

Arterial Blood Gases (ABGs)

SpO2

CXR

FOB: Fiberoptic Bronchoscopy


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Pneumococcal vaccine: recommended forthose >65 y/o or those with chronic anddebilitating diseases.

Medications used for treatment designed to

eradicate infection (ATBx) and improveventilation (bronchodilators).

Most ATBx carry the adverse effects ofdiarrhea, candidal infection, andsuperinfection.


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Increase fluids up to 3L/day. Incentive Spirometry

Endotracheal suctioning

Oxygenation

Chest Physiotherapy


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Postural Drainage Chest Percussion Controlled Coughing Deep Breathing


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Health promotion and prevention areparamount!

Health History should concentrate on currentsymptoms, characteristics of cough, sputum,

etc. Physical exam should concentrate on

respiratory system and the systems involvedin pneumonia and hypoxia.


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Ineffective Airway Clearance, IneffectiveBreathing Pattern,

Impaired Gas Exchange,

Knowledge Deficit

Activity Intolerance.

Remember to prioritize via ABC Physiologic

Psychosocial.


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Chronic, recurrent infectious BACTERIALdisease typically infecting the lungs as aresult ofMycobacterium tuberculosis.

Prevalence decreased with a resurgence in

the late 1980s and early 1990s as a result ofAIDS.

Prevalence continues to decline as a result of

improved surveillance and prevention efforts. HIV, and disadvantaged populations Highest

among immigrants, those infected w/HIV
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More than 2 billion people, equal to one-third of the worlds population, are infectedwith TB bacilli, the microbes that cause TB.

1 in 10 people infected with TB bacilli willbecome sick with active TB in their lifetime

1.8 million people died from TB in 2008,including 500 000 people with HIV - equal to4500 deaths a day


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Transmitted via droplet transmission whenperson speaks, coughs, or sneezes, or sings.

Droplets can suspend in air for hours,highlighting the significance of isolation.

The closer individuals are in contact with personsinfected, the higher the risk for transmission.

Droplet nuclei containing 1-3 bacilli implant inan alveolus or bronchiole, usually in an upper

lobe. Local inflammation results from rapid bacterial

multiplication.


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Cough (sometimes producing phlegm) Coughing up blood

Excessive sweating, especially at night

Fatigue

Fever

Unintentional weight loss


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Phagocytic (Neutrophils/Macrophages) surroundbacilli isolate but cannot destroy the bacilli,creating a granulomatous lesion called atubercle. The surrounding tissue dies frominfection, necrosing into a Swiss Cheese

appearance called Caseous Necrosis.

Scar tissue can develop around the tubercle; thebacilli remains encapsulated and calcifies. It liesdormant and the individual is a carrier of the

disease, or it becomes active (with improperimmune function) and the individual is activelyinfected.


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TB can also spread via the blood andlymphatics to the GU system, resulting inwidespread inflammation and destruction ofthe kidneys, ureters, and bladder

TB Meningitis, with resulting inflammation ofthe subarachnoid space (observe for changesin LOC, irritability, fever, anorexia, HA,vomiting, convulsions and coma; or as


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Erodes and collapses the vertebralbodies in spondylitis.


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Patient should be maintained on AirbornePrecautions.

PPD is used as a screening tool, + does not meanthe patient is actively infected.

Mantoux Test is read within 48-72 hours with thearea of induration (raised, scabbie erythema) ismeasured in millimeters.

Patients must be educated to complete drugregimens as prescribed.


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A positive skin test indicatesTB exposure and an inactiveinfection

People who have beenexposed to TB should be skintested immediately and havea follow-up test at a laterdate, if the first test isnegative.


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Some countries with a high incidence of TBgive people a BCG vaccination to prevent TB.

However, the effectiveness of this vaccine is

controversial and it is not routinely used inthe United States.

People who have had BCG will have a positivePPD skin test and will need a chest x-ray forscreening.


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3 Sputum samples with + AFB is the ONLY 100%diagnostic test for TB.

Collect sputum in AM x 3 days

C&S will be positive for M. tuberculosis

Chest X-ray reveals dense lesions in the apicaland posterior segments of the upper lobe w/possible cavitary formation.

Before initiating Drug therapy, LFTs, Optic

Examination, and Audiometric Testing should beperformed.


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Isoniazid (Nydrazid)((INH) Rifampin (Rifadin, Rimactane) (RIF) Ethambutol (Myambutol) (EMB) Pyrazinamide (PZA) Regimens for treating TB have an initial phase

of 2 months, followed by a choice of severaloptions for the continuation phaseof either 4or 7 months.


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Amikacin (Amikin) Ethionamide (Trecator)

Moxifloxacin (Avelox)

Para-aminosalicylic acid Streptomycin


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Adverse Effects of these Rxs includeHepatotoxicity

Check Liver Function Tests

Avoid ETOH and high doses of Tylenol

Orange discoloration of body fluids(important for contact lens wearerseducateclient).


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Prophylactic Tx used for carriers and thoseexposed to carriers

(INH 300mg PO QD x 6-12 months)

INH, Rifampin, and Pyrazinamide PO QD x 2months; then x 4months w/ INH & Rifampin.


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Resistance to TB drugs can occur when thesedrugs are misused or mismanaged. Examplesinclude

When patients do not complete their full

course of treatment; When health-care providers prescribe the

wrong treatment, the wrong dose, or wronglength of time for taking the drugs;

When the supply of drugs is not alwaysavailable When the drugs are of poor quality.


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Multidrug-resistant TB (MDR TB) is TB that isresistant to at least two of the best anti-TBdrugs, isoniazid and rifampin.

These drugs are considered first-line drugsand are used to treat all persons with TBdisease.


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Education and screening are paramount.

9-10 months of INH Tx reduces TB by 90%+.

Clinical improvement gauged via repeat CXRs.

Nursing Diagnosis must include Knowledge

Deficit (educate about disease process andthe toxicity of medications);


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Ineffective Therapeutic Regimen Management

Provide community links and resources forthe patient and educate the client about

proper medication schedule and adherence

Risk for (Communicable) Infection (place the

patient on Airborne Precautions in a roomwith airflow control


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Lower Respiratory Disorders Part 1

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