ALTERATIONS IN THE RESPIRATORY SYSTEM

1
ALTERATIONS IN THE RESPIRATORY SYSTEM

• Professor Cynthia Peacock R.N., M.S.N.

2

• Asthma
• Pneumonia
• Tuberculosis
• COPD
• Bronchitis
• Emphysema

3
Respiratory SystemFunctions for Ventilation

• Upper
• Warms and filters inspires air

• Lower
• Gas exchange- by delivering oxygen to the tissues
  thru the bloodstream and expels waste gases
  (carbon dioxide)

4
Risk Factors

• Smoking
• Exposure to secondhand smoke
• Personal/Family hx of lung disease
• Genetic make-up
• Allergens and environmental pollutants
• Recreational and occupational exposure

5
Assessment

• Health History
• Physical /Functional Pt. problems
• Is the pt. able to carry out ADLs?
• Question reason pt. is seeking healthcare
• Determine when the problem started, how long
  lasted, if relieved and how.
• Assess psych-social problems- (role change)
• Many resp. disases are chronic, and progressively
  debilitating and disabling.

6
Assessment

• Major S/S of respiratory disease are
• Dyspnea
• Cough
• Sputum production
• Chest pain
• Wheezing
• Clubbing of the fingers
• Hemoptysis
• Cyanosis

7
Dyspnea

• Difficult or labored breathing, breathlessness,
  shortness of breath)
• Occurs due to decrease lung compliance or
  increase airway resistance.
• Neurological or neuromuscular disorders
• After physical exercise-absence of disease
• End of life

8
Cause of Dyspnea must be determined

• Therefore, to manage you must id. And correct the
  cause.

• Suddenly in a healthy person may indicate
• Pneumothorax, Acute respiratory obstruction
  Acute respiratory distress syndrome)

• Inability to breath easily except in upright
  position (Orthopnea) may indicate heart disease
  or COPD.

9
Questions to ask the pt.

• How much exertion triggers SOB?
• Is their an associated cough?
• Is SOB related to other sx.?
• Onset- sudden or gradual?
• Occurrence DAY OR NIGHT?
• Is SOB worse when lying flat in bed?
• When does SOB occur? running, exercising, at
  rest, climbing stairs.
• Worst when walking- note how fast or how far.

10
COUGH

• Produced by infectious process, smoke, smog,
  dust.
• Reflex protecting the lung from accumulation of
  secretions

11
Clinical Significance

• Note time of coughing
• At night (bronchial asthma)
• Morning with sputum production- (bronchitis)
• Worsens when supine(sinusitis)
• After eating(aspiration)

• Note description
• Brassy tracheal lesion
• Dry, irritative- upper resp.
• tract infection (viral).
• Severe or changing
• bronchgenic carcinoma.

12
Classification

• If the cause of a cough has be identified and
  addressed and the cough continues, cough
  suppressants may be prescribed.
• Acute- lt 3 weeks
• Subacute 3 to 8 weeks
• Chronic more than 8 weeks
• (American College of Chest Physicians)

13
Sputum Production-Indications

• Bacterial infection- thick, yellow, green, or
  rust colored.
• .
• Viral bronchitis- thin, mucoid.
• Lung tumor- pink-tinged mucoid.
• Pulmonary edema- frothy, pink in the throat

14
Relief Measures

• Increase water intake/use of nebulizer will
  decrease the viscosity of the sputum allowing pt.
  to expectorate.
• Smoking- impairs bronchial drainage.

15
Nutrition

• Appetite may be decreased due to odor of the
  sputum or taste it leave in their mouth.
• Nurse encourages
• Good oral hygiene.
• Removal sputum cups, emesis basin and soiled
  tissue before mealtime.
• Drink citrus juice at the beginning of the
  meal-cleanses palate of sputum taste.

16
Chest Pain

• Pulmonary or Cardiac disease
• Clinical Significance
• Pleuritic pain sharp, on inspiration and is
  described like the stabbing of a knife- Pt.
  more comfortable lying on affected side thus
  splinting the chest wall, limiting lung expansion
  and contraction of the lung.
• In cancer- pain may be dull and persistent
  invaded chest wall, mediastium or spine.

17
Relief Measures

• Analgesics
• Nonsteroidal antiinflammatory drugs (NSAIDs)
• Regional anesthetic block

18
Assessment

• Wheezing brochoconstriction or airway
  narrowing, on expiration.
• Clubbing of fingers notes chronic hypoxic
  conditions, chronic lung infections or
  malignacies of the lung.
• Hemoptysis - Sx. Pulmonary and cardiac
  disease.1st determine source of bleeding.
• Cyanosis Late indication of hypoxia- bluish
  coloring of the skin. Assessment can be affected
  by room lighting, pt.s skin color, distance of
  blood vessels from the surface of the skin.

19
Diagnostic Evaluation

• Pulmonary Function Test
• Arterial Blood Gas Studies
• Pulse oximetry
• Cultures
• Sputum Studies
• Imaging Studies
• Endoscopic Procedures

20
Pulmonary Function Test (PFT)

• Routinely- Chronic resp. disorders
• Assess resp. function.
• Measures lung volume, ventilatory function,
  mechanics of breathing, diffusion and gas
  exchange.

21
PFT

• Useful- monitor course and response to therapy in
  a pt. with established resp. disease
• Screening test- hazardous industries
• Preop- thoraic or upper abd surgery or high risk
  pts.
• Evaluation disability insurance or legal
  purposes or dx. Occupational resp. disease.

22
ABG

• Assess ability of the lungs to provide adequate
  oxygen and remove carbon dioxide and ability of
  the kidney to reabsorb or excrete bicarbonate to
  maintain normal body pH.
• Obtained from arterial puncture

23
Pulse Oximetry 95-100 less than 85 tissues
not receiving enough oxygen

• Noninvasive, continuous way to monitor oxygen
  saturation.
• Good to monitor for sudden changes in oxygen
  saturation.
• Used in all settings- home, clinics, ambulatory
  surgical settings, hospitals
• A probe/sensor placed to fingertip, forehead,
  earlobe, bridge of nose

24
Testing

• Cultures Throat and nasal swabs are used to
  identify organisms responsible for pharyngitis.
• Sputum studies Id. Pathogenic organisms or
  presence of malignant cells.
• Deliver specimen within 2 hours to the lab.

25
Imaging

• CXR- shows flid, tumors, foreign bodies.
• Take after full inspiration optimal lung
  expansion.
• CT- Scanned in successive layers-cross-sectional
  view. Can define small tumors and pulmonary
  nodules.
• MRI more detailed image than CT. Uses magnetic
  fields and radiofrequency signals. Evaluate
  inflammatory activity in interstitial lung
  disease, acute pulmonary embolism.

26
Imaging

• Fluoroscopic- Assist with invasive procedures
  such as chest needle biopsy to id. lesions or
  locate lung masses.
• Pulmonary Angiography Examine thromboembolic
  disease of the lung. Ex. Pulmonary emboli,
  congenital abnormalities of the pulmonary
  vascular tree.
• Radioisotope Dx. Procedure- Lung Scan- assess
  normal lung functioning, pulmonary vascular
  supply and gas exchange. (V/Q, Gallium, PET).

27
Endoscopic Procedures

• Bronscopy direct inspection and examination of
  the larynx, trachea and bronchi .
• To diagnosis
• Examines tissue
• Collect secretions
• Note location/extent of pathological
  process/biopsy.
• Determine if tumor can be surgically re-sected.
• Diagnosis bleeding sites

28
Endoscopic Procedures

• Therapeutic
• Remove foreign bodies from tracheobronchial tree
• Remove secretions obstructing tracheobronchial
  tree
• Destroy and excise lesions
• Complications reaction to local anesthetic,
  infection, aspiration, bronchospasm, hyoxemia,
  pneumothorax, bleeding and perforation.

29
Nursing Intervention

• Assure consent form
• No food/fluid for 6 hours before the test
• Explain procedure
• Administer pre-op meds
• Remove dentures and other oral prosthesis
• After procedure
• NPO until cough reflex returns
• When cough reflex returns, offer ice chips and
  progress to fluids
• Monitor respiratory status

30
Objectives

• State 3 characteristics of Asthma.
• Discuss pathophysiology of Asthma.
• Discuss clinical manifestations of Asthma
• State factors contributing
• Note pharmacological therapy for treatment of
  Asthma

31
ASTHMA

• Chronic inflammatory obstructive disease
• Most common chronic childhood disease

32
CAUSES

• Allergies can be seasonal
• Airway irritants air pollution or perfumes
• Exercise, stress or emotional upsets

33
Pathophysiology

• Airway inflammation
• Inflammation leads to obstruction
• Obstruction due to
• Swelling of membranes that lines the airway
  reduced airway diameter
• Contraction of bronchial smooth muscle
  (bronchospasm)
• Increased mucus production- diminish airway size

34
Clinical Manifestations

• Cough
• Dyspnea
• Wheezing
• As exacerbation progresses Diaphoresis,
  tachycardia and widened pulse pressure along with
  hypoxemia

35
Assessment

• Complete family, environmental and occupational
  history.
• Acute phase- sputum and blood test may show
  elevated eosinophils

36

• Prevention
• If recurrent pt. should seek test to identify
  the substance that precipitate the symptoms.
• Complication
• Status asthmaticus, respiratory failure, and
  pneumonia.

37
Medical Management

• Pharmacological Therapy
• Quick relief meds
• Long acting meds
• Anti-inflammatory meds

38

• Managing exacerbations
• Early treatment and education
• Teach self management techniques
• Peak Flow Monitoring
• Measures highest airflow during a forced
  expiration. Zones Green 80- 100, Yellow
  60-80, Red less tan 60. Specific action are
  conducted for each zones.
• P.715- Smeltzer.

39
Status Asthmaticus

• Severe and persistent asthma that does not
  respond to conventional therapy.

40
Pneumonia
41
DescriptionInflammation of lung by various
microorganisms

• Caused by

• Classification

• Bacteria
• Mycobacteria
• Chlamydiae
• Mycoplasma
• Fungi
• Parasite
• Viruses

• Community Acquired
• Hospital Acquired
• Immunocompromised host
• Aspiration

42
Community Acquired (CAP)

• Occurs within the community or within first 48
  hours after hospitalization.
• In the United States CAP is the major cause of
  death from infectious disease.

43
CAP causes

• S. pneumoniae (pneumococcus)
• M. pneumoniae (Mycoplasm)
• H. influenzae

44
Hospital-Acquired Pneumonia

• Nosocomial
• Onset more than 48 hours after admission-no
  evidence of infection at the time of admission.
• Occurs
• Host defense are impaired
• Inoculum of organisms reaches the lower
  respiratory tract and overwhelms the hosts
  defense
• Highly virulent organism is present

45
HAP

• Enterobacter species , Escherichia coli, H.
  influenzae, MRSA.
• Presentation New pulmonary infiltrate on CXR
  combined with evidence of infection such as
  fever, ect.

46
Pneumonia in the Immunocompromised Host

• Pneumocystis pneumonia (PCP).
• Occurs with use of steriods or other
  immunosuppressive agents, chemotherapy,
  nutritional depletion, use of broad spectrum abx,
  AIDS,
• Presentation- subtle onset, progressive dyspnea,
  fever, and nonproductive cough.

47
Aspiration Pneumonia

• Common form of aspiration pneumonia is bacteria
  infection from aspiration of bacteria that
  normally resides in the upper airways
• Other substances that may be aspirated are
  gastric contents.

48
COPD
49
Chronic Obstructive Pulmonary Disease - (COPD)

• Incidence
• 4th leading cause of mortality
• Definition Disease state characterized by
  airflow limitation that is not fully reversible
• Subtypes Chronic Bronchitis
• Emphysema

50
Risk Factor

• People with COPD commonly become symptomatic
  during the middle and adult years and the
  incidence increases with age.
• Cigarette smoking is the most common cause of
  COPD. Breathing in other kinds of irritants, like
  pollution, dust or chemicals, may also cause or
  contribute to COPD. Quitting smoking is the best
  way to avoid developing COPD.

51
Pathophysiology

• In healthy people, both the airways and air sacs
  are springy and elastic. When you breathe in,
  each air sac fills with air like a small balloon.
  The balloon deflates when you exhale. In COPD,
  your airways and air sacs lose their shape and
  become floppy, like a stretched-out rubber band.

52
Chronic Bronchitis

• Disease of the airways
• Chronic cough
• Sputum production
• Increased mucous
• Chronic hypoxemia

53
Emphysema

• Impaired oxygen and CO2 exchange
• Results from destruction of the walls of
  overdistended alveoli
• Air trapping
• Hypoxemia, hypercapnia, resp. acidosis
• Right sided heart failure

54
Clinical Manifestations

• 3 primary symptoms
• chronic cough
• sputum production and
• Dyspnea on exertion
• Pursed lip breathing
• Barrel chest appearance
• Chronic hyperinflation

55
Pursed lip breathing

• Trapped, stale air is what causes shortness of
  breath. So before you can breathe in fresh air,
  you need to get the old air out. That's hard
  because of clogged, narrow airways or damaged air
  sacs deep in your lungs or both. When you breathe
  out slowly through pursed lips, you keep up the
  air pressure in your airways. That helps them
  stay open so that you can breathe out more stale
  air.

56
Assessment Diagnostic

• Pulmonary function test
• Severity progression
• Spirometry
• Evaluate airflow obstruction
• ABGs
• CXR (to r/o other dx)

57
Medical Management

• Risk Reduction
• Smoking cessation
• Pharmacological therapy
• Bronchodialtors
• Corticosteroids
• Others
• Pneumocococal vaccines
• Antibiotics
• Mucolytic agents antitussive agents

58
Medical Management cont.

• Oxygen therapy
• Long term
• More than 15 hours a day
• supplemental

59
Management of Acute Exacerbation of COPD

• Airway
• Oxygenation
• Mechanical Ventilation
• Pharmacological Treatment

60
Pharmacologic Management for COPD-Classifications

• Bronchodilators Promote smooth muscle relaxation
  of the airways
• Beta 2 agonist Short acting, Long acting
• Anticholinergic
• Methylxanthines
• Delivery methods Tablet, Liquid, MDI,
  Nebulizer