rispiratory disorders for nurses.pptxbb----

Medical-surgical nursing Management of patient with respiratory disorder 1/11/2023 1

Outline Anatomy and physiology overview Assessment of respiratory system Laboratory investigations and Diagnostic procedures 1/11/2023 2

Lesson objectives After completion of this session the students should be able to: Revise knowledge of anatomy and physiology Obtain health history about respiratory system Demonstrate physical examination Differentiate between normal and abnormal findings Identify investigations and diagnostic procedures 1/11/2023 3

Anatomy and physiologic overview extends from the nose to the alveoli and includes not only the air-conducting passages but also the blood supply The primary purpose - - Gas exchange divided into two parts: the upper respiratory tract the lower respiratory tract 1/11/2023 4

Anatomy and physiologic overview Cont.… Upper respiratory tract Nose Paranasal sinuses and conchae Pharynx, tonsils and adenoids Trachea Lower respiratory system Bronchi Bronchioles Lungs Pleura 1/11/2023 5

Anatomy and physiologic overview Cont.… Nose External and internal portion Opening Nasal mucosa Septum Function- filter impurities Warms air olfaction 1/11/2023 6

Anatomy and physiologic overview Cont.… Paranasal sinuses four pairs of bony cavities Frontal Ethmoidal Sphenoidal maxillary lined with nasal mucosa and ciliated pseudostratified columnar epithelium. Function- resonating chamber 1/11/2023 7

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Anatomy and physiologic overview cont.…. Pharynx- The conducting airways that connect nasal passages and mouth to the lower parts of the respiratory tract The pharyngeal tonsils, or adenoids, are situated in the posterior wall of the nasal cavity . Paired palatine tonsils are located on the posterior lateral wall , 1/11/2023 9

Anatomy and physiologic overview Cont.… The larynx , or “voice box,” is a continuation of the conducting division that connects the laryngopharynx with the trachea . Function prevent food or fluid from entering the trachea produce sound. The trachea , the “windpipe,” is a semi rigid , tubular organ, approximately 12 cm long and 2.5 cm in diameter, connecting the larynx to the principal (primary) bronchi A series of 16 to 20 C-shaped cartilages form the supporting walls of the trachea 1/11/2023 10

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Anatomy and physiologic overview cont.…. Lungs The lungs are paired elastic structures enclosed in the thoracic cage, which is an air tight chamber with distensible walls. 1/11/2023 12

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Anatomy and physiologic overview Cont.… The lungs and wall of the thorax are lined with a serous membrane called the pleura The visceral and parietal pleura MEDIASTINUM is in the middle of the thorax contains all the thoracic tissue outside the lungs. 1/11/2023 14

Anatomy and physiologic overview Cont.… LOBES The left lung consists of an upper and lower lobe, the right lung has an upper, middle, and lower lobe. BRONCHI AND BRONCHIOLES lobar bronchi segmental bronchi (10 on the right and 8 on the left) Sub segmental bronchi, bronchioles terminal bronchioles respiratory bronchioles alveolar ducts alveolar sacs alveoli 1/11/2023 15

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Anatomy and physiologic overview Cont.… ALVEOLI The lung is made up of about 300 million alveoli, 1/11/2023 17

FUNCTION OF THE RESPIRATORY SYSTEM The four basic functions of the respiratory system, not all of which are associated with breathing, are as follows: • It provides oxygen to the bloodstream and removes carbon dioxide . • It enables sound production or vocalization as expired air passes over the vocal folds. • It assists in abdominal compression during micturition (urination ), defecation (passing of feces), and parturition (childbirth ). • It enables protective and reflexive nonbreathing air movements, as in coughing and sneezing, to keep the air passageways clean . 1/11/2023 18

EXAMINATION OF RESPIRATORY SYSTEM 19 1/11/2023

Locating Findings on the Chest 20 Describe abnormalities of the chest in two dimensions: along the vertical axis and around the circumference of the chest. 1/11/2023

Locating vertically 21 Number ribs and interspaces accurately . Anteriorly, the sternal angle (Angle of Louis), Moving laterally from the Angle of Louis , you find the adjacent second rib and costal cartilage. Now you can walk down the inter spaces using your two fingers. An inter space is named by the rib above it . 1/11/2023

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Cont… 23 Posteriorly, the twelfth rib gives an other possible starting point for counting the ribs and inter spaces . This is especially useful in locating findings on the lower posterior ches t and also helps when the anterior approach is unsatisfactory. The inferior angle of the scapula lies at the level of the seventh rib or i nterspace 1/11/2023

Cont… 24 The spinous process of the seventh cervical vertebrae (When a person flexes his neck for ward, the most prominent process is usually that of the seventh cervical vertebrae, and when two processes appear equally prominent, they are of the seventh cervical and the first thoracic vertebrae .) helps to locate findings posteriorly. 1/11/2023

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Locating Findings Around The Circumference of The Chest 26 The mid sternal and vertebral lines precise ; others are estimated. These lines drop vertically in the middle of the sternum and the vertebral column respectively. The mid clavicular lines –drop vertically from the mid point of the clavicle 1/11/2023

Cont… 27 The anterior and posterior axillary lines- drop vertically from the anterior and posterior axillary folds (the muscle masses that border the axilla). The mid axillary lines - drop from the apexes of the axilla. The scapular lines – drop from the inferior angles of the scapulas 1/11/2023

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Lungs, fissures and lobes 29 Anteriorly , the apex of each lung rises about 2-4 cm above the inner third of the clavicle . The lower border of the lung crosses the sixth rib at the mid clavicular line and the eighth rib at the mid axillary line. 1/11/2023

Cont… 30 Posteriorly , the lungs extend from just above the scapula to about the level of the tenth thoracic spinous process on quite respiration. Each lung is divided about in half by an oblique (fissure). A string that runs from the third thoracic spinous process obliquely down and around the chest to the sixth rib at the mid clavicular line may approximate this fissure. 1/11/2023

Cont… 31 The right lung is further divided by the horizontal (minor) fissure. Anteriorly, this fissure runs close to the fourth rib and meets the oblique fissure in the mid axillary line near the fifth rib. There fore, the right lung has three lobes and the left lung has two lobes. 1/11/2023

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Locations on the Chest 35 Be familiar with general anatomic terms used to locate chest findings, such as: Supraclavicular—above the clavicles Infraclavicular—below the clavicles Interscapular—between the scapulae Infrascapular—below the scapula Bases of the lungs—the lower most portions Upper, middle, and lower lung fields 1/11/2023

The trachea and major bronchi 36 Breath sounds over the trachea and bronchi have a different quality than breath sounds over the lung parenchyma. Be sure you know the location of these structures. The trachea bifurcates into its main stem bronchi at the levels of the sternal angle anteriorly and the T4 spinous process posteriorly. 1/11/2023

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The Pleurae 38 The pleurae are serous membranes that cover the outer surface of each lung, the visceral pleura, and also line the inner rib cage and upper surface of the diaphragm, the parietal pleura. Their smooth opposing surfaces, lubricated by pleural fluid, allow the lungs to move easily within the rib cage during inspiration and expiration. The pleural space is the potential space between visceral and parietal pleurae. 1/11/2023

Examining the thorax and the lungs 39 General guidelines Expose the chest fully Proceed in an orderly fashion: inspection, palpation, percussion, and finally auscultation Compare one side with the other- Examine the posterior thorax and lungs while the patient is still in a sitting position. The patient’s arms should be folded across the chest with hands resting, if possible on the opposite shoulder as this position moves the scapula apart and increases your access to the lung fields. 1/11/2023

Cont… 40 Ask the patient to lie supine while examining the anterior chest. This position makes examining women easier, and wheezes, if present, are more likely to be heard. Other wise the sitting position is also satisfactory. When you must examine the chest by rolling to one side and to the other, percuss the upper lung and auscultate both lungs in each position. Because ventilation is relatively greater in the dependent lung, the chances of hearing wheezes or crackles are greater on the dependent side. 1/11/2023

Cont… 41 Relate all other findings in the thorax with findings such as shape of the finger nails and position of the trachea or cyanosis 1/11/2023

Common or Concerning Symptoms Of Respiratory System 42 Chest Pain: Complaints of chest pain or chest discomfort raise the specter of heart disease, but often arise from structures in the thorax and lung as well. To assess this symptom, you must pursue a dual investigation of both thoracic and cardiac causes. 1/11/2023

Sources of chest pain are listed below 43 The myocardium-Angina pectoris, myocardial infarction The pericardium-Pericarditis The aorta-Dissecting aortic aneurysm The trachea and large bronchi-Bronchitis The parietal pleura-Pericarditis, pneumonia The chest wall, including the musculoskeletal system and skin- Costochondritis , herpes zoster The esophagus-Reflux esophagitis, esophageal spasm Extrathoracic structures such as the neck, gallbladder, and stomach -Cervical arthritis, biliary colic, gastritis 1/11/2023

Dyspnea 44 is a nonpainful but uncomfortable awareness of breathing that is inappropriate to the level of exertion. This serious symptom warrants a full explanation and assessment, since dyspnea commonly results from cardiac or pulmonary disease. Ask “Have you had any difficulty breathing?” at rest or with exercise?, and how much effort produces onset?. Because of variations in age, body weight, and physical fitness, there is no absolute scale for quantifying dyspnea. Anxious patients may have episodic dyspnea during both rest and exercise, and hyperventilation, or rapid, shallow breathing. 1/11/2023

Wheezes 45 are musical respiratory sounds that may be audible both to the patient and to others. Wheezing suggests partial airway obstruction from secretions, tissue inflammation, or a foreign body. 1/11/2023

Cough 46 is a common symptom that ranges in significance from trivial to ominous. Typically, cough is a reflex response to stimuli that irritate receptors in the larynx, trachea, or large bronchi. These stimuli include mucus, pus, and blood external agents such as dusts, foreign bodies, or even extremely hot or cold air. inflammation pressure or tension in the air passages from a tumor or enlarged peribronchial lymph nodes. 1/11/2023

Cont… 47 For complaints of cough, Ask whether the cough is dry or produces sputum, or phlegm. the volume of any sputum and its color, odor, and consistency. Cough is an important symptom of left-sided heart failure. Dry hacking cough in Mycoplasmal pneumonia productive cough in bronchitis, viral or bacterial pneumonia Foul-smelling sputum in anaerobic lung abscess tenacious sputum in cystic fibrosis Large volumes of purulent sputum in bronchiectasis or lung abscess 1/11/2023

Hemoptysis 48 is the coughing up of blood from the lungs; it may vary from blood-streaked phlegm to frank blood. For patients reporting hemoptysis, assess the volume of blood produced as well as the other sputum attributes; ask about the related setting and activity and any associated symptoms. confirm the source of the bleeding by both history and physical examination. Blood or blood-streaked material may originate in the mouth, pharynx, or gastrointestinal tract and is easily mislabeled. 1/11/2023

Cont… 49 When vomited, it probably originates in the gastrointestinal tract. Occasionally, however, blood from the nasopharynx or the gastrointestinal tract is aspirated and then coughed out. Blood originating in the stomach is usually darker than blood from the respiratory tract and may be mixed with food particles. 1/11/2023

Cont… 50 Place your thumbs about at the level of and parallel to the tenth ribs posteriorly and at the level of the lower costal margin in the mid line anteriorly, your hands grasping the lateral rib cage. As you position your hands, slide them medially in order to raise loose skin folds between your thumbs. Ask the patient to breath deeply and watch the divergence of your thumbs or the return of the folds of skin during inspiration. 1/11/2023

Inspection 51 1.Inspect the shape of the chest. In the normal adult the thorax is wider than it is deep (the anterior-posterior diameter is about half of the transverse diameter). 1/11/2023

Cont… 52 A barrel chest A funnel chest is characterized by a depression in the lower portion of the sternum . Compression of the heart and great vessels may cause murmurs. A flail chest is unstable chest resulting when multiple ribs are fractured. Because descent of the diaphragm decreases intra thoracic pressure on inspiration, the injured area caves inward; on expiration, it moves outward (paradoxical respiration). 1/11/2023

Cont…. 53 In a pigeon chest , the sternum is displaced anteriorly , increasing the anterioposterior diameter. The costal cartilages adjacent to the sternum are depressed . In thoracic kyphoscoliosis , abnormal spinal curvatures and vertebral rotation deform the chest. Distortion of the underlying lungs may make interpretation of lung findings very difficult. 1/11/2023

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Cont… 56 Kyphosis-posterior curvature of the spine Lordosis - Anterior curvature of the spine Scoliosis-Lateral curvature of the spine 1/11/2023

2.Inspect respiratory pattern (rate, depth, rhythm, effort) 57 Normal respiration is 12-20 bpm per 4-6 seconds regular , quite and spontaneous . On quite respiration, the chest expands 1-2 inches in adults. 1/11/2023

Causes- restrictive lung diseases, pleuritc chest pain, and elevated diaphragm 1/11/2023 58

Causes- diabetic coma, drugs or increased intracranial pressure 1/11/2023 59

Cont… 60 deep breathing ( hyperpnea, hyper ventilation ) may be caused by exercise , anxiety , or metabolic acidosis among other causes. 1/11/2023

Cont… 61 Kussmaul breathing is deep breathing due to metabolic acidosis. 1/11/2023

Cont… 62 Cheyne -stokes breathing, periods of deep breathing alternate with periods of no breathing , may be normal in children and aging people during sleep. It may also have other sever causes such as heart failure , uremi a, drug induced respiratory depression , or brain damage (typically on both sides of the cerebral hemispheres or diencephalon). Brain damage at the medulary level causes ataxic breathing (breathing characterized by unpredictable irregularity). 1/11/2023

Cont… 63 In obstructive breathing, expiration is prolonged (longer than 6 seconds) because narrowed airways increase resistance to airflow. Causes include asthma , chronic bronchitis and emphysema . Contraction of the sternomastoid muscle or supra clavicular retractions during inspiration at rest signal sever difficulty in breathing . Intercostal and sub costal retractions suggest pulmonary stiffness whereas intercostal bulges during exhalation indicate emphysema. 1/11/2023

3.Observe for cyanosis 64 (blue discoloration of the skin, nail beds or mucous membrane when there is at least 5 gm % free Hgb in the blood) 1/11/2023

4. Movement of the Chest 65 One has to inspect wether both sides of the chest is moving symetrically or not.Causes of asymmetrical chest expansion are: Pleural effusion Pneumothorax Extensive consolidation Atelectasis Pulmonary Fibrosis 1/11/2023

Palpation 66 Palpation has the following uses: 1.Identification of tender areas : palpate any area where pain has been reported or lesions are evident. 2.Assessment of observed abnormalities example masses 3.Assessment of respiratory expansion to determine range and symmetry of respiratory movements. 1/11/2023

Cont… 67 Place your thumbs about at the level of and parallel to the tenth ribs posteriorly and at the level of the lower costal margin in the mid line anteriorly, your hands grasping the lateral rib cage. As you position your hands, slide them medially in order to raise loose skin folds between your thumbs. Ask the patient to breath deeply and watch the divergence of your thumbs or the return of the folds of skin during inspiration. 1/11/2023

Cont… 68 Normally divergence should be symmetrical and range of expansion should be not less than 1-2 inches . 1/11/2023

Cont… 69 4.Assessment of tactile fremitus (the palpable vibrations transmitted through the broncho- pulmonary tree to the chest wall when the patient speaks): Ask the patient to repeat words ‘99’ or ‘one-one-one’ and with the ball of your hand (the bony part of the palm at the base of the fingers) or the ulnar surface of your hand, palpate and compare symmetrical areas of the lung. 1/11/2023

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Cont… 71 Identify any areas of increased, decreased or absent fremitus and locate them. Fremitus is typically more prominent in the interscapular area than in the lower lung fields, and is often more prominent on the right side than on the left. It disappears below the diaphragm. 1/11/2023

Cont… 72 Fremitus is decreased or absent when the voice is soft , the transmissions of the vibrations from the larynx to the surface of the chest wall is impended as in obstructed bronchus, chronic obstructive diseases, separation of the pleural surfaces by fluid , air, fibrosis (pleural thickening), infiltrating tumor or when there is very thick chest wall . On the contrary, fremitus is increased when transmission is increased as through the consolidated lung of lobar pneumonia. 1/11/2023

Percussion 73 Percussion of the thorax has three main purposes: To determine whether the underlying tissues are air filled, fluid filled or solid with in 5-7 cm in to the chest wall. To estimate diaphragmatic excursion To identify level of diaphragmatic dullness 1/11/2023

Cont… 74 Techniques: Hyper extend the middle finger of your left hand ( pleximeter finger) and press its distal iterphalangeal joint on the surface to be percussed (avoid surface contact by any other part of the hand as it dumps the vibrations). Position your right forearm quite close to the surface with the hand cocked up ward and, with a quick, sharp, but relaxed wrist motion strike the pleximetre finger with the tip of the partially right middle finger. 1/11/2023

Cont … 75 You should always use the lightest percussion that produces a clear note; a thick chest wall requires heavier percussion than a thin one. Remember to keep your technique constant in comparing two areas. 1/11/2023

Cont… 76 Interpretation of percussion findings is based on the following five percussion notes: Flat - this is a type of note we get by percussing over the thigh ; pathological examples include massive pleural effusion , tumor , etc. Dull : a type of note similar to the one detected over normal liver . Pathological examples include lobar pneumonia, pleural effusion, hemothorax , etc. 1/11/2023

Cont… 77 Resonance : this is the percussion note of normal lung tissue though it can’t rule out lung abnormalities. Pathological example, chronic bronchitis. Hyper resonance : this note is detected when there is larger amount of air contained under the surface to be percussed as in emphysema and bronchial asthma (in which case it is generalized) or pneumothorax (in which case it is localized). Tympani : this note can be learned by percussing over a puffed out cheek or over most areas of the stomach. Pathological example, large pneumothorax. 1/11/2023

Identifying The Level Of Diaphragmatic Dullness 78 Starting above the expected level of dullness, percuss down ward until resonance replaces dullness during quiet respiration. Check the level of this change near the middle of the hemi thorax and also more laterally . An abnormally high level may suggest pleural effusion, or high diaphragm as from atelectasis or diaphragmatic paralysis 1/11/2023

Estimating Diaphragmatic Excursion 79 Ask the patient to exhale fully and keep. Percuss the posterior chest down from area of resonance to area of dullness and mark. Then ask the patient to breath in deep and hold, continue percussing down until resonance changes to dullness and mark. Measure the vertical distance between the two points. Do the same for the other side. Normally it should be 5-6 cm, with the possibility of the right side to be 2cm higher than the left side. 1/11/2023

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Auscultation 81 It is the most important examining technique for assessing airflow through the broncho -tracheal tree. Instruct the patient to breath deeply through an open mouth. Using the diaphragm of the stethoscope, auscultate areas suggested by percussion and compare symmetrical areas. You should auscultate between the ribs not at the ribs. In children, the interspaces are small and there fore you better use the bell of your stethoscope pressed tightly. 1/11/2023

Cont… 82 If you hear or suspect abnormality, auscultate adjacent areas to describe the extent of the abnormality. Be alert for patient discomfort due to hyperventilation (example light headedness, faintness), and allow the patient to rest as needed. 1/11/2023

Cont… 83 Auscultation has the following three main purposes: To identify whether the breath sounds are decreased, absent or abnormally located To identify the presence of added (adventitious) sounds To identify extent of transmission of voice sounds 1/11/2023

The Normal Breath Sounds 84 1.Vesicular breath sound that is characteri zed by: Inspiratory sounds lasting longer than expiratory ones Soft and low pitched No pause between expiration and inspiration Heard through inspiration and one–third of expiration Normally heard over most of both lungs 1/11/2023

2.Bronchial Breath 85 sound that is characterized by: Loud and relatively high pitched Expiratory sounds lasting longer than inspiratory ones Short silent period between inspiration and expiration The normal location is over the manubrium if heard at all 1/11/2023

3.Broncho-Vesicular Breath 86 sounds are characterized by: Intermediate in intensity and pitch Inspiratory and expiratory sounds are about equal in duration A silent gap between inspiration and expiration may or may not be present Normally it can be heard in the first and second interspaces anteriorly and between the scapulas posteriorly 1/11/2023

Cont… 87 If bronchial or broncho -vesicular sounds are heard in locations distant from those listed, suspect that air filled lung has been replaced by fluid filled or solid lung tissue. 1/11/2023

Cont… 88 Breathed sounds may be decreased when airflow is decreased (example obstructive lung disease or muscular weakness) or when the transmission of sound is poor (example in pleural effusion, pneumothorax, or emphysema). 1/11/2023

Added Sounds 89 These are sounds that are superimposed on the usual breath sounds. The common ones are described here. Crackles/ rales /crepitation : discontinuous/intermittent, nonmusical sounds of brief-like dots in time that may be fine (soft and brief) or coarse (louder and not quit so brief). Crackles are caused by air babbles flowing through secretions or lightly closed airways during respiration . 1/11/2023

Cont… 90 They also result from a series of tiny explosions when small airways, deflated during expiration, pop open during inspiration (Example interstitial lung disease, early congestive heart failure, pneumonia). If you hear crackles, note whether fine or coarse, their timing in the respiratory cycle, location on the chest wall, persistence of their pattern from breath to breath and any change after coughing or changing position. 1/11/2023

Cont… 91 Note also that in some normal people, crackles may be heard at the lung bases anteriorly after maximal expiration, and that crackles in dependent portions of the lungs may also occur after prolonged recumbency . Wheezes: relatively high-pitched, continuous, musical sounds which are longer than crackles and like dashes in time. Wheezes are often audible through mouth or chest wall. 1/11/2023

Cont… 92 It occurs when air flows through bronchi that are narrowed to the point of closure. Generalized wheezes are commonly caused by asthma, chronic bronchitis and congestive heart failure. A persistent localized wheeze suggests a partial obstruction of a bronchus , as by a tumor or foreign body. It may be inspiratory, expiratory or both. 1/11/2023

Cont… 93 Stridor i s a wheeze that is entirely or predominantly inspiratory. It indicates a partial obstruction of the larynx or trachea and is a medical emergency. Rhonchi are continuous sounds with snoring quality; it suggests secretions in the larger airways. 1/11/2023

Cont… 94 Pleural friction rub : Are discrete granting sounds that appear continuous because they are numerous. Pleural friction rub are usually confined to a small area of chest wall and typically heard in both phases of the respiration. 1/11/2023

Transmitted voice sounds 95 If you hear abnormally located broncho -vesicular breath sounds or bronchial breath sounds, continue on to assess transmitted voice sounds. This can be done in the following ways. Ask the patient to say ‘99’,’ arba-arat ’ or ‘ afurtemi-afur ’ as applicable and auscultate over the auscultatory areas with your stethoscope. Normally the sounds transmitted through the chest wall are muffled and indistinct. Louder clearer voice sounds heard through the stethoscope ( bronchophony ) suggest that air-filled lung has become airless. 1/11/2023

Cont… 96 Ask the patient to say ‘ ee ’. Normally, you hear a muffled long “e”. When ‘ ee ’ is heard as ‘ay’, an e-to-a change, ( egohpony ), and the quality sounds nasal, it suggests that the lung has been changed to airless. Ask the patient to whisper ‘99’ or one-two-three’ and auscultate. The whispered voice is normally heard faintly and indistinctly. Louder clearer whispered sounds (whispered pectoriloquy ) suggest airless lung. 1/11/2023

Diagnostic evaluation Pulmonary function tests (PFTs) are routinely used in patients with chronic respiratory disorders. They are performed to assess respiratory function and to determine the extent of dysfunction . measurements of lung volumes, ventilatory function, and the mechanics of breathing, diffusion, and gas exchange 1/11/2023 97

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Diagnostic evaluation- Cont’d ARTERIAL BLOOD GAS STUDIES Measurements of blood pH and of arterial oxygen and carbon dioxide tension PULSE OXIMETRY noninvasive method of continuously monitoring the oxygen saturation of hemoglobin CULTURES Throat cultures may be performed to identify organisms responsible for pharyngitis 1/11/2023 100

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Diagnostic evaluation- Cont’d 1/11/2023 102

Diagnostic evaluation- Cont’d 1/11/2023 103

Diagnostic evaluation- Cont’d SPUTUM STUDIES In general, sputum cultures are used in diagnosis, for drug sensitivity testing , and to guide treatment. 1/11/2023 104

Diagnostic evaluation- Cont’d- imaging studies Chest X-Ray Normal pulmonary tissue is radiolucent; therefore, densities produced by fluid, tumors, foreign bodies, and other pathologic conditions can be detected by x-ray examination The postero -anterior projection and the lateral projection. Chest x-rays are usually taken after full inspiration because the lungs are best visualized when they are well aerated 1/11/2023 105

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Diagnostic evaluation- Cont’d Computed Tomography lungs are scanned in successive layers by a narrow-beam x-ray define pulmonary nodules and small tumors demonstrate mediastinal abnormalities and hilar adenopathy Contrast agents are useful 1/11/2023 107

Diagnostic evaluation- Cont’d 1/11/2023 108

Diagnostic evaluation- Cont’d Magnetic Resonance Imaging MRI uses magnetic fields and radiofrequency signals characterize pulmonary nodules stage bronchogenic carcinoma evaluate inflammatory activity in interstitial lung disease acute pulmonary embolism, and chronic thrombolytic pulmonary hypertension 1/11/2023 109

Diagnostic evaluation- Cont’d 1/11/2023 110

Diagnostic evaluation- Cont’d Fluoroscopic Studies Fluoroscopy is used to assist with invasive procedures, such as a chest needle biopsy or transbronchial biopsy Pulmonary Angiography used to investigate thromboembolic disease of the lungs, such as pulmonary emboli and congenital abnormalities of the pulmonary vascular tree 1/11/2023 111

Diagnostic evaluation- Cont’d 1/11/2023 112 Fluoroscopic Studies

Diagnostic evaluation- Cont’d- ENDOSCOPIC PROCEDURES Bronchoscopy Bronchoscopy is the direct inspection and examination of the larynx , trachea, and bronchi through either a flexible fiber-optic bronchoscope or a rigid bronchoscope It can be diagnostic or therapeutic 1/11/2023 113

Diagnostic evaluation- Cont’d- ENDOSCOPIC PROCEDURES DIAGNOSTIC to examine tissues or collect secretions to determine the location and extent of the pathologic process and to obtain a tissue sample for diagnosis to determine if a tumor can be resected surgically, a to diagnose bleeding sites (source of hemoptysis ). Therapeuti c remove foreign bodies from the tracheobronchial tree , remove secretions obstructing the tracheobronchial tree treat postoperative atelectasis destroy and excise lesions . 1/11/2023 114

Diagnostic evaluation- Cont’d- ENDOSCOPIC PROCEDURES 1/11/2023 115

Diagnostic evaluation- Cont’d- ENDOSCOPIC PROCEDURES Thoracoscopy Thoracoscopy is a diagnostic procedure in which the pleural cavity is examined with an endoscope THORACENTESIS aspiration of pleural fluid for diagnostic or therapeutic purposes BIOPSY the excision of a small amount of tissue, may be performed to permit examination of cells from the pharynx, larynx, and nasal passages 1/11/2023 116

Diagnostic evaluation- Cont’d- ENDOSCOPIC PROCEDURES 1/11/2023 117

Diagnostic evaluation- Cont’d- ENDOSCOPIC PROCEDURES Pleural Biopsy Pleural biopsy is accomplished by needle biopsy of the pleura or by pleuroscopy , Performed when there is pleural exudate of undetermined origin and when there is a need to culture or stain the tissue to identify tuberculosis or fungi . Lung Biopsy Procedures transcatheter bronchial brushing transbronchial lung biopsy percutaneous ( through-the-skin) needle biopsy. 1/11/2023 118

Management of Patients With Upper Respiratory Tract Disorders 1/11/2023 119

Upper Respiratory Tract Infections/Inflammatory Disorders Are the common conditions that affect most people on occasion , some infections are acute and other are chronic Patients with these conditions seldom require hospitalization . 1/11/2023 120

Case scenario A 25 year old student came to the class with running nose, sneezing and intermittent coughing. When you questioned what happens to him the condition started a day back with scratchy throat and currently he feels body warmth, discomfort. You observed that his nose become red, no eye color change and use tissue paper very frequently. What would be the most likely diagnoses of this student? If you are a nurse caring for him how do you manage his condition? 1/11/2023 121

common cold The term “common cold” often is used when referring to an upper respiratory tract infection that is self-limited and caused by a virus (viral rhinitis). Cold referred to afebrile, infectious, acute inflammation, of the mucus membranes of the nasal cavity More broadly, the term refers to an acute upper respiratory tract infection ,( non-specific URI ) whereas terms such as “rhinitis,” “pharyngitis,” and “laryngitis” distinguish the sites of the symptoms . Colds are highly contagious because virus is shed for about 2 days before the symptoms appear and during the first part of the symptomatic phase. 1/11/2023 122

common cold-Etiology Rhinovirus Para-influenza virus coronavirus , respiratory syncytial virus ( RSV) influenza virus adenovirus . 1/11/2023 123

common cold-Clinical manifestations Nasal congestion Rhinorrhea Scratchy or sore throat Sneezing & cough Headache & muscle ache Herpes simplex sore (cold sore ) general malaise, low-grade fever, chills The symptoms last from 1 to 2 weeks 1/11/2023 124

common cold- symptomatic management Fluid intake ,rest ,prevention of chills . Warm salt-water gargles decongestant( Chlorpheneramine , 4mg P.O. TID for adults), anti histamine, Vit . C. dextromethorphan for cough SNIP Analgesic for aches ,pain , & fever. Nursing Management Patient teaching of self care & prevention of infection & break chain of infection 1/11/2023 125

Pharyngitis ( sorethroat ) acute chronic 1/11/2023 126

Acute Pharyngitis It is a febrile inflammation of throat ,caused by virus about 70% , uncomplicated viral infection usually subsided promptly within 3-10 days It is symptom rather than a disease Caaused by Common cold and flu( Viraletiology ) Strep throat-- group A beta-hemolytic streptococcus Mononucleosis(Viral) Pseudomembranous pharyngitis Vesicular pharyngitis Ulcero -necrotic pharyngitis Fungal Allergy Dry indoor air chronic mouth breathing GERD 1/11/2023 127

Complications of untreated bacterial pharyngitis Local complication Peritonsilar , retropharyngeal or lateral pharyngeal abscess : General complication Complications due to the toxin: diphtheria Poststreptococcal complications: ARF, acute glomerulonephritis. Signs of serious illness in children: severe dehydration, severe difficulty swallowing , upper airway compromise, deterioration of general condition.. 1/11/2023 128

Clinical Manifestations Fiery red pharyngeal membrane& tonsils Lymphoid follicles that are swollen Enlarged tender cervical lymph node Fever & malaise Sore throat , hoarseness,& cough 1/11/2023 129

Assessment and Diagnostic Findings History and physical examination Laryngoscope Rapid screening tests for streptococcal antigens such as the Latex agglutination (LA) antigen test solid-phase enzyme immunoassays (ELISA ), optical immunoassay (OIA), streptolysin titers, throat cultures are used to determine the causative organism, Nasal swabs and blood cultures 1/11/2023 130

Medical Management Supportive measures for viral infection analgesic for severe sore antitussive medications: Guaifenesin Nutritional therapy liquid or soft diet “If liquid can’t tolerated IV fluid administered “ 1/11/2023 131

Antibiotics benzathine benzylpenicillin IM adults : 1.2 MIU single dose Penicilin V is the oral reference treatment , 1 g 2 times daily Amoxicilin is an alternative 1 g 2 times daily azithromycin PO for 3 days 500 mg once daily 1/11/2023 132

Nursing Management bed rest Used tissue should be disposed skin assessment mouth care Ice collar normal saline gargle self care teaching 1/11/2023 133

Chronic Pharyngitis Common in adults who work or live in dusty surrounding ,use the voice too excess , suffer from chronic cough , & habitually use alcohol & tobacco Types of pharyngitis Hypertrophic : ch.ch.by general thickening& congestion of pharyngeal mucus membrane Atrophic : probably late stage of first type Chronic Granular : ch.ch.by numerous swollen lymph follicles on the pharyngeal wall 1/11/2023 134

Clinical Manifestations Constant sense of irritation or fullness in throat Mucus expelled by coughing Difficulty in swallowing 1/11/2023 135

Medical Management Relieving symptoms Avoiding exposure to irritant Correct respiratory & cardiac conditions Nasal sprays or medications containing ephedrine sulfate or phenylephrine hydrochloride Aspirin or acetaminophen is recommended for its anti-inflammatory and analgesic properties. 1/11/2023 136

Tonsillitis and Adenoidits The tonsils are composed of lymphatic tissue & situated on each side of the oropharynx ,they frequently are the site of acute infection (tonsillitis) Tonsillitis occurs when the filtering function becomes overwhelmed with a virus or bacteria and infection results The adenoids, a mass of lymphoid tissue located at the back of the nasopharynx Tonsillitis is more common in children 1/11/2023 137

Etiology The most common organisms causing tonsillitis are Streptococcus species , Staphylococcus aureus Haemophilus influenzae Pneumococcus species . 1/11/2023 138

Clinical Manifestations Tonsillitis : Swelling of the tonsils Redder than normal tonsils A white or yellow coating on the tonsils A slight change in the voice due to swelling Sore throat sometimes accompanied by ear pain Uncomfortable or painful swallowing Swollen lymph nodes (glands) in the neck Fever Bad breath 1/11/2023 139

Adenoiditis Breathing through the mouth instead of the nose most of the time Nose sounds “blocked” when the person speaks Chronic runny nose Noisy breathing during the day Recurrent ear infections Snoring at night Restlessness during sleep, or pauses in breathing for a few seconds at night 1/11/2023 140

Complications Otitis media Mastoditis Permanent deafness Management Antimicrobial therapy “penicillin” for 7 days 1/11/2023 141 History P/E RSAT Culture from throat Audiometric examination if complication occurs Assessment and Diagnostic Findings

Indications for Tonsillectomy repeated bouts of tonsillitis; hypertrophy of the tonsils and adenoids that could cause obstruction and obstructive sleep apnea; repeated attacks of purulent otitis media ; suspected hearing loss due to serous otitis media Exacerbation of asthma or rheumatic fever . 1/11/2023 142

Nursing Management Provide post op. care :V/S ,hemorrhage , position head turned to side , water or ice chips Teaching patient :S&S of hemorrhage Avoid too much talking or coughing Liquid or semi liquid diet for several days mouth washing with warm saline 1/11/2023 143

PERITONSILLAR ABSCESS A peritonsillar abscess is a collection of purulent exudate between the tonsillar capsule and the surrounding tissues, including the soft palate. It is believed to develop after an acute tonsillar infection, which progresses to a local cellulitis and abscess. 1/11/2023 144

Clinical Manifestations a raspy voice, odynophagia dysphagia otalgia (pain in the ear), and drooling. An examination shows marked swelling of the soft palate , often occluding almost half of the opening from the mouth into the pharynx, tonsillar hypertrophy, and dehydration . 1/11/2023 145

Medical management Antibiotics- effective Incision needed if no response to antibiotics Ansthetic spray ------ aspirating by needle or incision and draining Sitting position- helps expectoration of pus and blood 30% of client with peritonsillar abscess require tonsillectomy 1/11/2023 146

Nursing intervention Encourage rest. Encourage your child to get plenty of sleep. Provide adequate fluids. ... Provide comforting foods and beverage. ... Prepare a saltwater gargle. ... Humidify the air. ... Avoid irritants. ... Treat pain and fever. frequent use of mouthwashes or gargles, using saline or alkaline solutions at a temperature of 105°F to 110°F (40.6°C to 43.3°C). The nurse instructs the patient to gargle at intervals of 1 or 2 hours for 24 to 36 hours . 1/11/2023 147

Laryngitis It is an inflammation of larynx ,often occur as a result of voice abuse or exposure to dust , chemicals , smoke , & other pollutants Common in winter & easily transmitted The cause of infection is almost virus Clinical Manifestations Hoarseness or aphonia Severe cough 1/11/2023 148

Medical Management Resting voice & avoid smoking Inhale cool steam or an aerosol Antibiotics for bacterial organisms Nursing Management Rest voice Maintain a well humidified environment Daily fluid intake 1/11/2023 149

NURSING PROCESS: THE PATIENT WITH UPPER AIRWAY INFECTION Assessment Health history headache, Sore throat pain around the eyes and on either side of the nose, Difficulty in swallowing, cough , hoarseness, fever, stuffiness Generalized discomfort and fatigue . history of allergy 1/11/2023 150

P/E swelling, lesions, or asymmetry of the nose as well as bleeding or discharge increased redness, swelling, or exudate, and nasal polyps Sinus tenderness Throat inspection Tracheal palpation 1/11/2023 151

NURSING DIAGNOSES Impaired Gas exchange related to retained secretions and inflammation as evidenced by decrease O2 saturation Acute pain related to upper airway irritation secondary to an infection Impaired verbal communication related to physiologic changes and upper airway irritation as evidenced by aphonia Deficient fluid volume related to increased fluid loss as evidenced by tachycardia, decrease BP and poor skin turgor Deficient knowledge regarding prevention of upper respiratory infections , treatment regimen, surgical procedure, or postoperative care 1/11/2023 152

COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS Sepsis Meningitis Peri-tonsillar abscess Otitis media Sinusitis 1/11/2023 153

Planning and Goals maintenance of a patent airway , relief of pain maintenance of effective means of communication normal hydration knowledge of how to prevent upper airway infections absence of complications. 1/11/2023 154

Nursing Interventions MAINTAINING A PATENT AIRWAY Increasing fluid intake Use of room vaporizers or steam inhalation Position- upright position Administer prescribed medication PROMOTING COMFORT Analgesics topical anesthetic agents 1/11/2023 155

Hot packs to relieve the congestion of sinusitis and promote drainage warm water gargles or irrigations to relieve the pain of a sore throat encourages rest to relieve the generalized discomfort general hygiene techniques to prevent the spread of infection ice collar may reduce swelling and decrease bleeding- post- operative 1/11/2023 156

PROMOTING COMMUNICATION The nurse instructs the patient to refrain from speaking as much as possible and to communicate in writing instead ENCOURAGING FLUID INTAKE The nurse encourages the patient to drink 2 to 3 L of fluid per day during the acute stage of airway infection, unless contraindicated 1/11/2023 157

PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care how to minimize the spread of infection avoid exposure to others at risk for serious illness Relieve symptoms of upper respiratory infections Complete the treatment regimen 1/11/2023 158

MONITORING AND MANAGING POTENTIAL COMPLICATIONS The patient and family members are instructed to seek medical care if the patient’s condition fails to improve within several days of the onset of symptoms , if unusual symptoms develop, or if the patient’s condition deteriorates . 1/11/2023 159

Evaluation Expected patient outcomes may include: 1 . Maintains a patent airway by managing secretions a. Reports decreased congestion b. Assumes best position to facilitate drainage of secretions 2. Reports feeling more comfortable a. Uses comfort measures: analgesics, hot packs, gargles, rest b. Demonstrates adequate oral hygiene 3. Demonstrates ability to communicate needs, wants, level of comfort 1/11/2023 160

4. Maintains adequate fluid intake 5. Identifies strategies to prevent upper airway infections and allergic reactions a. Demonstrates hand hygiene technique b. Identifies the value of the influenza vaccine 6. Demonstrates an adequate level of knowledge and performs self-care adequately 7. Becomes free of signs and symptoms of infection a. Exhibits normal vital signs (temperature, pulse, respiratory rate) b. Absence of purulent drainage c. Free of pain in ears, sinuses, and throat 1/11/2023 161

Management of Patients With Chest and Lower Respiratory Tract Disorders 1/11/2023 162

Conditions affecting the lower respiratory tract range from acute problems to long-term chronic disorders. Many of these disorders are serious and often life-threatening. 1/11/2023 163

Atelectasis Atelectasis refers to closure or collapse of alveoli and often is described in relation to x-ray findings and clinical signs and symptoms . may be acute or chronic May be micro atelectasis or macro atelectasis Causes Postoperative obstruction of airflow with mucus chronic airway obstruction by cancer Compression of lung tissue from effusion or a tumor 1/11/2023 164

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Pp Airway obstruction the trapped alveolar air absorbed outside air cannot replace the absorbed air isolated portion of the lung becomes airless alveoli collapse 1/11/2023 166

Assessment findings Clinical effects vary with the causes of lung collapse, the degree of hypoxia , and the underlying disease Minimal symptoms Cough sputum production lobar atelectasis marked respiratory distress dyspnea , tachypnea , hypoxemia hall mark of severity Tachycardia , pleural pain, and central cyanosis 1/11/2023 167

Inspection decreased chest wall movement, cyanosis, diaphoresis, substernal or intercostal retractions, and anxiety . Palpation may reveal decreased fremitus and mediastinal shift to the affected side 1/11/2023 168

Percussion may disclose dullness or flatness over lung fields . Auscultation findings may include crackles during the last part of inspiration and decreased (or absent) breath sounds with major lung involvement. 1/11/2023 169

Diagnostic tests chest x-ray findings may reveal patchy infiltrates or consolidated areas pulse oximetry (SpO2 ) may demonstrate a low saturation of hemoglobin ABG- low partial pressure (paO2) and acidosis Bronchoscopy – obstructing tumor 1/11/2023 170

Management The goal in treating the patient with atelectasis is to improve ventilation by remove secretions Incentive spirometer Chest physiotherapy Humidity and bronchodilator medications Positive End-expiratory pressure or PEEP therapy continuous or intermittent positive pressure-breathing (IPPB ) Bronchoscopy Thoracentesis surgery or radiation therapy 1/11/2023 171

Nursing diagnoses Acute pain Anxiety Deficient knowledge (prevention) Fear Impaired gas exchange Ineffective airway clearance Ineffective breathing pattern Risk for infection 1/11/2023 172

Nursing interventions coughing and deep-breathing exercises every 1 to 2 hours Splint the chest to minimize the pain help him walk as soon as possible . Administer adequate analgesics to control pain . Monitor mechanical ventilation. Maintain tidal volume at 10 to 15 ml/kg of the patient's body weight to ensure adequate lung expansion 1/11/2023 173

Monitor pulse oximetry for decreases in oxygenation . Help the patient use an incentive spirometer to encourage deep breathing Humidify inspired air, and encourage adequate fluid intake to mobilize secretions. Use postural drainage and chest percussion to remove secretions For the intubated or uncooperative patient, provide suctioning Assess breath sounds and respiratory status frequently. Report changes immediately 1/11/2023 174

Prevention frequent turning, early mobilization Deep-breathing maneuvers (at least every 2 hours ) Secretion management techniques may include directed cough, suctioning, aerosol nebulizer treatments followed by chest physical therapy 1/11/2023 175

Lower Respiratory Tract Infections 1/11/2023 176

ACUTE TRACHEOBRONCHITIS an acute inflammation of the mucous membranes of the trachea and the bronchial tree , often follows infection of the upper respiratory tract . Etiology A patient with a viral infection has decreased resistance and can readily develop a secondary bacterial infection. inhalation of physical and chemical irritants , gases, and other air contaminants 1/11/2023 177

Mos Streptococcus pneumoniae Haemophilus influenzae Mycoplasma pneumoniae . Aspergillus fumigatus 1/11/2023 178

Pp Chemicals, mos irritation of mucosa mucopurulent sputum 1/11/2023 179

Clinical Manifestations Initially , the patient has a dry , irritating cough and expectorates a scanty amount of mucoid sputum The patient complains of sternal soreness from coughing and has fever or chills and night sweats , headache, and general malaise . As the infection progresses, the patient may be short of breath , have noisy inspiration and expiration (inspiratory stridor and expiratory wheeze), and produce purulent sputum With severe tracheobronchitis , blood-streaked secretions may be expectorated 1/11/2023 180

Medical Management Antibiotic treatment Expectorants may be prescribed-Guaifenesin, 200- 400 mg P.O. QID- Fluid intake is increased Suctioning and bronchoscopy may be needed to remove secretions . Rarely, endotracheal intubation– ARF Dextromethorphan hydrobromide , 15 – 30 mg P.O. TID to QID for adults. 1/11/2023 181

Nursing Management encourage bronchial hygiene, such as increasing fluid intake and directed coughing to remove secretions. Advise full course of antibiotics prescribed 1/11/2023 182

PNEUMONIA Pneumonia is an inflammation of the lung parenchyma that is caused by a microbial agent. “ Pneumonitis ” is a more general term that describes an inflammatory process in the lung tissue that may predispose a patient to or place a patient at risk for microbial invasion. 1/11/2023 183

Pneumonia was described 2,500 years ago by Hippocrates Dr. William Osler described pneumonia the “captain of the men of death” Before the advent of antibiotics – 3 rd leading cause of death 2006- 8 th leading cause of death in USA 1/11/2023 184 Before antibiotics, pneumonia was the third-leading cause of death in the country, as this cover of a 1937 U.S. government publication attests.

Classification Bacterial/Typical Atypical anaerobic/ cavitary opportunistic A more widely used classification scheme community-acquired pneumonia Hospital acquired pneumonia pneumonia in the immuno -compromised host aspiration pneumonia 1/11/2023 185

Community-acquired pneumonia (CAP) occurs either in the community setting or within the first 48 hours of hospitalization or institutionalization . Pneumonia caused by S. pneumoniae (pneumococcus ) most common CAP in people younger than 60 without comorbidity and in those older than 60 with comorbidity may occur as a lobar or bronchopneumonic form 1/11/2023 186

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Mycoplasma pneumonia , another type of CAP, occurs most often in older children and young adults spread by infected respiratory droplets. The inflammatory infiltrate is primarily interstitial rather than alveolar has the characteristics of a bronchopneumonia . 1/11/2023 188

H. influenzae is another cause of CAP. It frequently affects elderly people or those with comorbid illnesses ( eg , chronic obstructive pulmonary disease [COPD], alcoholism, diabetes mellitus ). Chest x-rays may reveal multilobar , patchy bronchopneumonia or areas of consolidation 1/11/2023 189

Viruses are the most common cause of pneumonia in infants and children but are relatively uncommon causes of CAP in adults. 1/11/2023 190

immunocompetent influenza viruses types A and B , adenovirus, parainfluenza virus, coronavirus , varicella-zoster virus. immunocompromised cytomegalovirus herpes simplex virus , adenovirus, respiratory syncytial virus. 1/11/2023 191

Hospital-acquired pneumonia (HAP), also known as nosocomial pneumonia , is defined as the onset of pneumonia symptoms more than 48 hours after admission to the hospital . Ventilator-associated pneumonia- endotracheal intubation and mechanical ventilation. 1/11/2023 192

The common organisms responsible for HAP include Enterobacter species Escherichia coli Klebsiella species , Serratia marcescens P. aeruginosa methicillin-sensitive or methicillin-resistant Staphylococcus aureus 1/11/2023 193

HAP occurs Host defenses are impaired an inoculum of organisms reaches the patient’s lower respiratory tract and overwhelms the host’s defenses, a highly virulent organism is present. 1/11/2023 194

Pneumonia in the immunocompromised host Pneumocystis carinii pneumonia (PCP ) fungal pneumonias Mycobacterium tuberculosis Immunocompromization may be due to Drugs- corticosteroids, chemotherapy , nutritional depletion, AIDS , genetic immune disorders mechanical ventilation 1/11/2023 195

Aspiration pneumonia results from the entry of endogenous or exogenous substances into the lower airway. aspiration of bacteria that normally reside in the upper airways. Aspiration pneumonia may occur in the community or hospital setting; common pathogens S. pneumoniae , H. influenzae S . aureus . Other substances may be aspirated into the lung, such as gastric contents, exogenous chemical contents, or irritating gases. This type of aspiration or ingestion may impair the lung defenses, cause inflammatory changes , and lead to bacterial growth and a resulting pneumonia. 1/11/2023 196

Pathophysiology Lower airway is normally sterile Mos access the lung through- Inhalation of virulent mos Aspiration of upper airway flora Hematogeniuos spread Extension from nearby structure 1/11/2023 197

Pneumonia often affects both ventilation and diffusion . Alveoli occupied with Inflammatory exudate WBC-mostly neutrophils Bronchospasm and secretion- reduce entry of air This leads to ventilation- perfusion mismatch 1/11/2023 198

Risk factors Alcoholism Asthma Immunosuppresion Institutinalization Age >=70 1/11/2023 199

Clinical Manifestations Sudden onset of shaking chills Cough Rapidly increase in body temperature 38.5-40.5 C Pleuratic Chest pain increased by deep breathing Patient looks severely ill with marked tachypnea Shortness of breath Orthopnea Poor appetite Diaphoresis &tires easily Purulent sputum 1/11/2023 200

Assessment and Diagnostic Findings history physical examination chest x-ray studies blood culture- bacteremia 1/11/2023 201

Medical Management Appropriate antibiotics depend on culture result Hydration (increase fluid intake ) Antipyretic for fever Super infection & Headache Warm moist inhalation to relieve irritation Oxygen & respiratory supportive measures Complications : Shock & respiratory failure , Atelectasis & plural effusion 1/11/2023 202

1/11/2023 203 CURB-65 C-Confusion=1point U-Uremia: BUN >19mg/ dL =1point R-RR >30/min= 1point BP <90/60=1point Age >=65=1point

Community acquired ambulatory patients (Mild Pneumonia ) First line No recent antibiotic use : Clarithromycin , 500 mg P.O. BID for 5-7 days OR Azitromycin , 500mg P.O first day then 250mg P.O. for 4d. OR Doxycycline , 100 mg P.O. BID for 7-10 days. 1/11/2023 204

If recent antibiotic use within 3months : Clarithromycin, 500 mg P.O. BID for 5-7 days OR Azitromycin , 500mg P.O first day then 250mg P.O. for 4d. PLUS Amoxicillin , 1000 mg P.O. TID for 5 to 7 days. OR Amoxicillin- clavulanate , 625mg P.O. TID for 5-7days 1/11/2023 205

Community acquired hospitalized patients (Severe Pneumonia) First line Ceftriaxone , 1 g I.V. OR I.M every 12-24 hours for 7 days. OR Benzyl penicillin, 2-3 million IU I.V. QID for 7-10 days. PLUS Azithromycin , 500 mg on day 1 followed by 250 mg/day on days 2 – 5 OR Clarithromycin, 500mg P.O. BID for 7-10 days 1/11/2023 206

Hospital acquired pneumonias (Nosocomial Pneumonias): First line Ceftazidime , 1 gm I.V. TID for 10-14days PLUS Vancomycin 1g I.V. BID for 10-14 days OR Imipenem-cilastatin , 500mg IV (infused slowly over 1hour) Q6h OR Menopenem , 1gm IV (infused slowly over 30min) Q8h 1/11/2023 207

Alternatives Ceftriaxone , 1-2 gI.V . OR I.M. BID for 7 days. PLUS Gentamicin , 3-5 mg/kg I.V. QDdaily in divided doses for 7 days . OR Ciprofloxacin, 500 mg P.O./ I.V. BID for 7 days . If methicillin-resistant (MRSA) suspected Vancomycin , 1 g I.V. BID should be added to the existing emperic regimen 1/11/2023 208

Nursing diagnoses Acute pain Anxiety Hyperthermia Imbalanced nutrition: Less than body requirements Impaired gas exchange Ineffective airway clearance Ineffective coping Risk for deficient fluid volume Risk for infection 1/11/2023 209

Nursing interventions Maintain a patent airway and adequate oxygenation Obtain sputum specimens as needed Administer antibiotics as ordered and pain medication as needed Provide a high-calorie, high-protein diet To prevent aspiration during nasogastric tube feedings, elevate the patient's head, check the tube position, and administer the feeding slowly Monitor the patient's fluid intake and output 1/11/2023 210

To control the spread of infection, dispose of secretions properly Provide a quiet, calm environment, with frequent rest periods 1/11/2023 211

Pleural Conditions 1/11/2023 212

are disorders that involve the visceral pleura, parietal pleura and pleural space. PLEURISY Pathophysiology Pleurisy ( pleuritis ) refers to inflammation of both layers of the pleurae (parietal and visceral). Pleurisy may develop in conjunction Infection(pneumonia or URTI, TB,)or collagen disease; trauma to the chest, pulmonary infarction, pulmonary embolism primary and metastatic cancer after thoracotomy. 1/11/2023 213

Clinical Manifestations The pleuritic pain – parietal pleura Pain characterstics Taking a deep breath, coughing, or sneezing worsens the pain restricted in distribution rather than diffuse; usually occurs only on one side become minimal or absent when the breath is held as pleural fluid develops, the pain decreases. Assessment and Diagnostic Findings a pleural friction rub can be heard with the stethoscope friction rub disappear later as more fluid accumulates Diagnostic tests may include chest x-rays, sputum examinations, thoracentesis to obtain a specimen of pleural fluid for examination , and less commonly a pleural biopsy. 1/11/2023 214

Medical Management discover the underlying condition causing the pleurisy and to relieve the pain. monitor for signs and symptoms of pleural effusion analgesics provide symptomatic relief. intercostal nerve block may be required. Nursing Management Pain management Splinting when coughing . 1/11/2023 215

PLEURAL EFFUSION Pleural effusion, a collection of fluid in the pleural space, is rarely a primary disease process but is usually secondary to other diseases. Normally , ( 5 to 15 mL), which acts as a lubricant Pleural effusion Cause heart failure, TB, pneumonia, pulmonary infections (particularly viral infections), nephrotic syndrome , connective tissue disease, pulmonary embolism, and neoplastic tumors. Bronchogenic carcinoma is the most common malignancy associated with a pleural effusion. 1/11/2023 216

Pathophysiology The effusion can be composed of a relatively clear fluid, or it can be bloody or purulent. An effusion of clear fluid may be a transudate or an exudate 1/11/2023 217

Clinical Manifestations Severity The size of the effusion and the patient’s underlying lung disease the time course of the development A large : shortness of breath. When a small to moderate :dyspnea may be absent or only minimal. 1/11/2023 218

Assessment and Diagnostic Findings decreased or absent breath sounds , decreased fremitus , and a dull, flat sound when percussed . In an extremely large pleural effusion, acute respiratory distress. Tracheal deviation away from the affected side may also be noted. chest x-ray, chest CT scan, and thoracentesis confirm the presence of fluid Pleural fluid is analyzed by bacterial culture, Gram stain, acid fast bacillus stain (for TB), red and white blood cell counts, chemistry studies (glucose, amylase, lactic dehydrogenase, protein), cytologic analysis for malignant cells, and pH. A pleural biopsy also may be performed. 1/11/2023 219

Medical Management The objectives discover the underlying cause, prevent reaccumulation of fluid, to relieve discomfort, dyspnea , and respiratory compromise. Thoracentesis chemical pleurodesis Surgical pleurectomy , insertion of a small catheter attached to a drainage bottle for outpatient management, or implantation of a pleuroperitoneal shunt 1/11/2023 220

Nursing Management The nurse’s role in the care of the patient with a pleural effusion includes implementing the medical regimen. The nurse prepares and positions the patient for thoracentesis and offers support throughout the procedure. Pain management is a priority, and the nurse assists the patient to assume positions that are the least painful . However , frequent turning and ambulation are important to facilitate drainage. If a chest tube drainage and water-seal system is used, the nurse is responsible for monitoring the system’s function and recording the amount of drainage at prescribed intervals. If the patient is to be managed as an outpatient with a pleural catheter for drainage, the nurse is responsible for educating the patient and family regarding management and care of the catheter and drainage system. 1/11/2023 221

EMPYEMA An empyema is an accumulation of thick, purulent fluid within the pleural space, often with fibrin development and a loculated (walled-off ) area where infection is located. Most empyemas occur as complications of bacterial pneumonia or lung abscess. Other causes include penetrating chest trauma, hematogenous infection of the pleural space, nonbacterial infections, or iatrogenic causes (after thoracic surgery or thoracentesis ). Pathophysiology At first the pleural fluid is thin, with a low leukocyte count, but it frequently progresses to a fibropurulent stage and, finally, to a stage where it encloses the lung within a thick exudative membrane ( loculated empyema). 1/11/2023 222

Clinical Manifestations With an empyema, the patient is acutely ill and has signs and symptoms similar to those of an acute respiratory infection or pneumonia (fever, night sweats, pleural pain, cough, dyspnea, anorexia , weight loss). If the patient is immuno -compromised , the symptoms may be more vague. If the patient has received antimicrobial therapy , the clinical manifestations may be less obvious. Assessment and Diagnostic Findings decreased or absent breath sounds over the affected area, and there is dullness on chest percussion as well as decreased fremitus. The diagnosis is established by a chest x-ray or chest CT scan. Usually a diagnostic thoracentesis is performed, often under ultrasound guidance. 1/11/2023 223

Medical Management The objectives of treatment are to drain the pleural cavity and to achieve full expansion of the lung. The fluid is drained and appropriate antibiotics , in large doses, are prescribed based on the causative organism . Sterilization of the empyema cavity requires 4 to 6 weeks of antibiotics. Drainage of the pleural fluid depends on the stage of the disease and is accomplished by one of the following methods : • Needle aspiration ( thoracentesis ) with a thin percutaneous catheter , if the volume is small and the fluid not too purulent or thick • Tube thoracostomy (chest drainage using a large-diameter intercostal tube attached to water-seal drainage with fibrinolytic agents instilled through the chest tube in patients with loculated or complicated pleural effusions • Open chest drainage via thoracotomy, including potential rib resection, to remove the thickened pleura, pus, and debris and to remove the underlying diseased pulmonary tissue 1/11/2023 224

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Nursing Management The nurse helps the patient cope with the condition and instructs the patient in lung-expanding breathing exercises to restore normal respiratory function . The nurse also provides care specific to the method of drainage of the pleural fluid ( eg , needle aspiration, closed chest drainage , or rib resection and drainage). When a patient is discharged to home with a drainage tube or system in place, the nurse instructs the patient and family on care of the drainage system and drain site, measurement and observation of drainage, signs and symptoms of infection, and how and when to contact the health care provider 1/11/2023 226

Pulmonary Edema Pulmonary edema is defined as abnormal accumulation of fluid in the lung tissue and/or alveolar space . It is a severe, life threatening condition . Pathophysiology occurs as a result of increased microvascular pressure from abnormal cardiac function. left ventricular dysfunction hypervolemia or a sudden increase in the intravascular pressure in the lung. example pneumonectomy . “flash ” pulmonary edema .(post op , fluid overload) re-expansion pulmonary edema. Sudden expansion of lung 1/11/2023 227

Assessment and Diagnostic Findings crackles in the lung bases (especially in the posterior bases) that rapidly progress toward the apices of the lungs . The chest x-ray reveals increased interstitial markings . The patient may be tachycardic , the pulse oximetry values begin to fall, and arterial blood gas analysis demonstrates increasing hypoxemia. Clinical Manifestations The patient has increasing respiratory distress, characterized by dyspnea , air hunger, and central cyanosis. The patient is usually very anxious and often agitated . foamy, frothy, and often blood-tinged secretions. The patient has acute respiratory distress and may become confused or stuporous . 1/11/2023 228

Nursing Management Positioning the patient to promote circulation Providing psychological support Monitoring medications Medical Management Management focuses on correcting the underlying disorder. Vasodilators , inotropic medications, afterload or preload agents diuretics Oxygen is administered to correct the hypoxemia; in some circumstances, intubation and mechanical ventilation are necessary. The patient is extremely anxious, and morphine is administered to reduce anxiety and control pain . 1/11/2023 229

Acute Respiratory Failure Respiratory failure is a sudden and life-threatening deterioration of the gas exchange function of the lung. exchange of oxygen for carbon dioxide in the lungs cannot keep up with the rate of oxygen consumption and carbon dioxide production by the cells of the body. Acute respiratory failure (ARF) is defined as a fall in arterial oxygen tension (PaO2) to less than 50 mm Hg (hypoxemia) and a rise in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg ( hypercapnia ), with an arterial pH of less than 7.35. In ARF, the ventilation or perfusion mechanisms in the lung are impaired . Respiratory system mechanisms leading to ARF include: • Alveolar hypoventilation • Diffusion abnormalities • Ventilation–perfusion mismatching 1/11/2023 230

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Pathophysiology Common causes of ARF can be classified into four categories DECREASED RESPIRATORY DRIVE : severe brain injury, large lesions of the brain stem use of sedative medications , and metabolic disorders such as hypothyroidism . DYSFUNCTION OF THE CHEST WALL : any disease or disorder of the nerves, spinal cord, muscles, or neuromuscular junction DYSFUNCTION OF LUNG PARENCHYMA : Pleural effusion, hemothorax , pneumothorax, and upper airway obstruction are conditions that interfere with ventilation by preventing expansion of the lung. OTHER CAUSES postoperative period, especially after major thoracic or abdominal surgery 1/11/2023 232

Acute Respiratory Failure Clinical Manifestations Impaired oxygenation & may be include restlessness Fatigue & headache Dyspnea & air hunger Tachycardia &hypertension Confusion & lethargy Diaphoresis …… Respiratory Arrest Uses of accessory muscles 1/11/2023 233

Acute Respiratory Failure Medical management: Intubations and mechanical ventilation may be required to maintain adequate ventilation and oxygenation while the case corrected 1/11/2023 234

Acute Respiratory Failure Nursing management: Monitoring patient responses and arterial blood gases Monitoring vital sign turning ,mouth care , skin care , and range of motion . Teaching about the underlying disorders Assists in intubations procedure 1/11/2023 235

Pulmonary Embolism Obstruction of a pulmonary artery by a blood borne substance. Deep vein thrombosis is a common cause of pulmonary embolism. Other types (Air , Fat , Septic ) Clinical Manifestations Dyspnea & Tachypnea Sudden & pluretic chest pain Fever & cough & hemoptesis Apprehension Diaphoresis & syncope 1/11/2023 236

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Pulmonary Embolism Medical Management Emergency Management Nasal O 2 IV line for Medication ABGs &ECG Small dose of Morphine Intubation & mechanical Ventilation 1/11/2023 238

Pulmonary Embolism Pharmacologic Management Anticoagulant therapy heparin 5000-10000 bolus then 18u/kg/ hrs warfarin for three months (2-5mg) Thrombolytic therapy (Streptokinase IV 250,000 units over 30 min, then 100,000 units/ hfor 24–72 h) Surgical Management (Surgical Embolectomy ) 1/11/2023 239

Pulmonary Embolism Nursing Management Preventing thrombus formation Monitoring thrombolytic therapy Providing post operative nursing care Managing O 2 therapy Preventing anxiety Monitor for complications 1/11/2023 240

Pneumothorax/Hemothorax Traumatic disorders of the respiratory tract wherein the underlying lung tissue is compressed and eventually collapses. Types Simple Pnuemothrax Traumatic Pnuemothorax Tension 1/11/2023 241

Pneumothorax/Hemothorax Clinical Manifestations Sudden pluretic pain Anxious patient , dyspnea & air hunger Increase use of accessory muscles Central cyanosis Tympanic sound in percussion Absent of breath sound & tactile fremetus Agitation Diaphoresis & hypotension 1/11/2023 242

Pneumothorax/Hemothorax Medical Management High concentration supplemental O2 Chest tube for drainage In emergency anything may be use to fill the chest wound Heavy dressing Needle aspiration thoracenthesis Connecting chest tube to water seal drainage An emergency thoractomy may also performed 1/11/2023 243

Pulmonary Heart Disease ( Cor Pulmonale ) Cor pulmonale is a condition in which the right ventricle of the heart enlarges (with or without right-sided heart failure) as a result of diseases that affect the structure or function of the lung or its vasculature. causes Any disease affecting the lungs and accompanied by hypoxemia may result in cor pulmonale . The most frequent cause is severe COPD conditions that restrict or compromise ventilatory function , leading to hypoxemia or acidosis (deformities of the thoracic cage, massive obesity) conditions that reduce the pulmonary vascular bed (primary idiopathic pulmonary arterial hypertension , pulmonary embolus ). Certain disorders of the nervous system , respiratory muscles, chest wall, and pulmonary arterial tree also may be responsible for cor pulmonale . 1/11/2023 244

Pathophysiology Pulmonary disease can produce physiologic changes that in time affect the heart and cause the right ventricle to enlarge and eventually fail . Any condition that deprives the lungs of oxygen can cause hypoxemia and hypercapnia , resulting in ventilatory insufficiency. Hypoxemia and hypercapnia cause pulmonary arterial vasoconstriction and possibly reduction of the pulmonary vascular bed The result is increased resistance in the pulmonary circulatory system, with a subsequent rise in pulmonary blood pressure (pulmonary hypertension). A mean pulmonary arterial pressure of 45 mm Hg or more may occur in cor pulmonale . Right ventricular hypertrophy may result, followed by right ventricular failure. 1/11/2023 245

Clinical Manifestations With right ventricular failure, the patient may develop increasing edema of the feet and legs distended neck veins an enlarged palpable liver pleural effusion, ascites a heart murmur. Headache , confusion, and somnolence ( hypercapnia). Patients often complain of increasing shortness of breath, wheezing , cough, and fatigue. 1/11/2023 246

Medical Management The objectives of treatment are to improve the patient’s ventilation to treat both the underlying lung disease and the manifestations of heart disease. Supplemental oxygen is administered to improve gas exchange and to reduce pulmonary arterial pressure and pulmonary vascular resistance . 1/11/2023 247

1/11/2023 248 Periodic assessment of pulse oximetry and arterial blood gases is necessary to determine the adequacy of alveolar ventilation and to monitor the effectiveness of oxygen therapy. Ventilation is further improved with chest physical therapy and bronchial hygiene maneuvers the administration of bronchodilators .

If the patient is in respiratory failure , endotracheal intubation and mechanical ventilation may be necessary. Bed rest, sodium restriction, and diuretic therapy Digitalis may be prescribed to relieve pulmonary hypertension if the patient also has left ventricular failure, a supraventricular dysrhythmia, or right ventricular failure that does not respond to other therapy. ECG monitoring may be indicated Any pulmonary infection must be treated promptly The prognosis depends on whether the pulmonary hypertension is reversible. 1/11/2023 249

Nursing Management If intubation and mechanical ventilation are required to manage ARF, the nurse assists with the intubation procedure and maintains mechanical ventilation. The nurse assesses the patient’s respiratory and cardiac status and administers medications as prescribed. During the patient’s hospital stay, the nurse instructs the patient about the importance of close monitoring (fluid retention, weight gain, edema) and adherence to the therapeutic regimen, especially the 24-hour use of oxygen. 1/11/2023 250

chronic lung disease ASTHMA 1/11/2023 251

Objectives Identify signs and symptoms consistent with asthma Differentiate the various severities of asthma Summarize an appropriate treatment regimen for asthma of various severities 1/11/2023 252

Bronchial asthma It is recurrent air way disease affecting bronchus with bronchoconstriction Asthma is a chronic inflammatory disease of the airways that causes airway hyperresponsiveness , mucosal edema , and mucus production . It Is due to hyperesponsiviness of airways and also airways flow limitations , and fundamentally inflammatory disorder. 1/11/2023 253

Definition of Asthma Chronic inflammatory disorder of the airways in which many cells and cellular elements play a role. In susceptible individuals, this inflammation causes recurrent episodes of wheezing , breathlessness , chest tightness , and coughing, particularly at night or in the early morning. These episodes are associated with widespread but variable airflow obstruction that is reversible either spontaneously, or with treatment. Patients with asthma may experience symptom-free periods alternating with acute exacerbations , which last from minutes to hours or days 1/11/2023 254

Causes of asthma 1. Irritants such as: Tobacco smoke Exercise* Exposure to work-related agents or indoor chemicals; and Outdoor pollutants * Despite its potential to be a trigger, with a proper warm up, people with exercise-induced asthma should be able to engage in physical activity 1/11/2023 255

2. Allergens such as Pollen Moulds Dust mites Pet dander Foods or food additives and Cockroach allergen 1/11/2023 256

Other factors that can trigger or worsen asthma severity: Upper respiratory infections Rhinitis/Sinusitis Gastroesophageal reflux Sensitivity to aspirin and other NSAIDS and Topical and systemic beta-blockers 1/11/2023 257

Risk factors for developing asthma Family history of allergy and allergic disorders (including hay fever, asthma and eczema) High exposure of susceptible children to airborne allergens in the first years of life 1/11/2023 258

Exposure to tobacco smoke, including inutero exposure Frequent respiratory infections early in life Low birth weight and respiratory distress syndrome 1/11/2023 259

Prevalence of Asthma 1/11/2023 260

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Global Asthma Prevalence Approximately 262 million people worldwide currently have asthma Asthma death 455000 by the end of 2019 Studies have shown that asthma is more prevalent in urban areas than in less polluted areas 1/11/2023 262

Asthma is the leading chronic disease of children in industrialized countries It is estimated that asthma accounts for about one in every 250 deaths worldwide 1/11/2023 263

CF and severity of asthma Mild to moderate severe Respiratory failure Speaking speaks sentences Words Can't speak Mental status Conscious Agitated confused RR <30/min >30/min >30 PR <120/min > 120/ min,pale PR or BP Low Accessory muscles None Retractions,pale,sweat Paradoxic , cyanoses Wheezes during exhalation Very strong Absent,no air movement 1/11/2023 264

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ii. Intermittent asthma First line Salbutamol, inhaler 200 microgram/puff, 2 puffs to be taken as needed but not more than 3-4 times a day, or tablet, 2-4mg 3-4 times a day 1/11/2023 275

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iv. Persistent moderate asthma: Salbutamol , inhalation 200/puff as needed PRN not more than 3-4 times a day. PLUS (Inhaled corticosteroid) Beclomethasone , oral inhalation 200 mcg, bid. Decrease the dose to 100mcg, BID if symptoms are controlled after three months. OR (Preferred if symptoms are mor severe or if response is not optimal to Beclomethasone ) Fluticasone/ Salmeterol , 250/50 mcg oral inahalation , BID PLUS ( if required) Ephedrine + Theophylline, 11mg + 120mg P.O. BID OR TID v. Severe persistent asthma: Prednisolone, 5-10 mg P.O. QOD. Doses of 20-40 mg daily for seven days may be needed for short-term exacerbations in patients not responding to the above treatment. 1/11/2023 277

Chronic Obstructive Pulmonary Disease 1/11/2023 278 Chronic Obstructive Pulmonary Disease

Chronic Obstructive Pulmonary Disease COPD is “a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible. The air flow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases.” GOLD 1/11/2023 279

Chronic Obstructive Pulmonary Disease cont …. 1/11/2023 280

Chronic Obstructive Pulmonary Disease cont.…. Pathophysiology Noxious particles or gases abnormal inflammatory response . The inflammatory response occurs throughout the airways, parenchyma, and pulmonary vasculature . narrowing occurs in the small peripheral airways. Over time, this injury-and-repair process causes scar tissue formation and narrowing of the airway lumen. Airflow obstruction may also be due to parenchymal destruction as seen with emphysema, a disease of the alveoli or gas exchange units . 1/11/2023 281

Chronic Obstructive Pulmonary Disease cont.…. When activated by chronic inflammation, proteinases and other substances may be released, damaging the parenchyma of the lung . 1/11/2023 282

Chronic Bronchitis Chronic bronchitis, a disease of the airways , is defined as the presence of cough and sputum production for at least 3 months in each of 2 consecutive years . Characteristics Chronic irritation Increased goblet cells Narrowed airway Decreased function of macrophages Increased mucus secretion Ciliary function reduced Increased susceptibility to infection 1/11/2023 283

Emphysema In emphysema , impaired gas exchange (oxygen, carbon dioxide) results from destruction of the walls of over distended alveoli. “Emphysema” is a pathological term that describes an abnormal distention of the air spaces beyond the terminal bronchioles, with destruction of the walls of the alveoli . It is the end stage of a process that has progressed slowly for many years 1/11/2023 284

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Characteristics of Emphysema Destroyed alveolar wall Decreased pulmonary capillary contact with alveolar wall Increased dead space Impaired O2 diffusion(hypoxemia) and CO2 elimination( hypercapnia ) More blood remain in the pulmonary arteries and the right ventricle Cor-pulmonale 1/11/2023 286

Two types of emphysema Panlobar ( panacilar ) there is destruction of the respiratory bronchiole , alveolar duct , and alveoli . All air spaces within the lobule are essentially enlarged barrel chest marked dyspnea on exertion, and weight loss The chest becomes rigid 1/11/2023 287

Centrilobular ( centriacinar ) pathologic changes take place mainly in the center of the secondary lobule Preserving the peripheral portions of the acinus derangement of ventilation–perfusion ratios hypoxemia, hypercapnia right-sided heart failure central cyanosis, peripheral edema, and respiratory failure 1/11/2023 288

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Risk factors Exposure to tobacco smoke accounts for an estimated 80% to 90 % of COPD cases Passive smoking Occupational exposure Ambient air pollution Genetic abnormalities, including a deficiency of alpha1- antitrypsin , an enzyme inhibitor that normally counteracts the destruction of lung tissue by certain other enzymes 1/11/2023 290

Clinical Manifestations three primary symptoms: Cough sputum Production dyspnea on exertion Weight loss barrel chest 1/11/2023 291

Assessment and Diagnostic Findings Spirometry is used to evaluate airflow obstruction Obstructive lung disease is defined as a FEV1/FVC ratio of less than 70 %. Arterial blood gas measurements alpha1 antitrypsin deficiency 1/11/2023 292

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1/11/2023 295 Step up the treatment based on the severity of COPD I. Mild COPD Rapid-acting bronchodilator when needed II. Moderate COPD Add regular treatment with one or more long-acting bronchodilators Add pulmonary rehabilitation (including exercise training ) III. Severe COPD Add medium- to high-dose inhaled steroids IV. Very severe COPD- - Long-term oxygen if chronic respiratory failure - Consider surgical referral

1/11/2023 296 Inhaled ß2 agonist – Salbutamo l, MDI, 200 mcg 6 hourly as needed using a spacer. PLUS Inhaled corticosteroids and long acting inhaled beta -2 agonist Beclomethasone , oral inhalation 200 mcg , bid. Decrease the dose to 100mcg , BID if symptoms are controlled after three months. OR (Preferred if symptoms are more severe or if response is not optimal to Beclomethasone ) Fluticasone/ Salmeterol , 250/50 mcg oral inhalation , BID Dosage forms: PLUS Theophedrine (Ephedrine + Theophylline), P.O, 131 mg 12 hourly. Doasage forms - Tablet, 11mg + 120mg PLUS Long term home O 2 (>15 hrs per day) - For patients with resting hypoxemia with signs of pulmonary hypertension or right heart failure , the use of O2 has been demonstrated to have a significant impact on mortality rate.

1/11/2023 297 Management of Acute exacerbation Oxygen - via nasal cannula or facemask for hypoxic patients to keep O2 saturation above 90% PLUS Short-acting beta2 agonists Salbutamo l, MDI, 200 mcg 6 hourly as needed using a spacer PLUS Corticosteroids Prednisolone, 30- 40mg/day or its equivalent for7-14 . PLUS Antibiotic therapy- in patients with a moderate to severe COPD exacerbation (increased dyspnea, increased sputum volume, or increased sputum purulence or requiring hospitalization) First line for moderate exacerbation managed as out patient Doxycycline 100, mg, p.o. BID for 7 days OR Azithromycin 500mg, p.o. daily for 3days OR Clarithromycin 500mg, p.o , BID for 7 days If there is high risk for Pseudomonas (frequent use of antibiotics, recent admission and frequent use of antibiotics) PLUS Ciprofloxacin 500mg , p.o , BID for 7 days Alternative Cefuroxime 500mg, p.o. , BID for 7 days Amxicillin / Clavulanate 500/165 mg, p.o , TID for 7

1/11/2023 298 For severe exacerbations requiring hospitalization Ceftriaxone , 1gm, IV, BID for 7-10 days or until discharge whichever is shorter. On discharge change to oral antibiotic mentioned above PLUS Doxycycline 100mg, oral, BID OR Clarithromycin 500mg, oral, BID

SURGICAL MANAGEMENT Bullectomy . Lung Volume Reduction Surgery involves the removal of a portion of the diseased lung parenchyma . This allows the functional tissue to expand, resulting in improved elastic recoil of the lung and improved chest wall and diaphragmatic mechanics may decrease dyspnea, improve lung function, and improve the patient’s overall quality of life. Lung Transplantation. Lung transplantation is a viable alternative for definitive surgical treatment of end-stage emphysema 1/11/2023 299

Nursing Management The nurse plays a key role in the management of COPD Breathing Exercises Pursed lip breathing helps to slow expiration prevents collapse of small Airways helps the patient to control the rate and depth of respiration. 1/11/2023 300

Inspiratory Muscle Training the patient breathe against resistance for 10 to 15 minutes every day . Activity Pacing . planning self-care activities and determining the best time for bathing, dressing, and daily activities . Self-Care Activities . The patient is taught to coordinate diaphragmatic breathing with activities such as walking, bathing, bending, or climbing stairs. 1/11/2023 301

Physical Conditioning . Graded exercises and physical conditioning programs using treadmills, stationary bicycles, and measured level walks can improve symptoms and increase work capacity and exercise tolerance. There is a close relationship between physical fitness and respiratory fitness . Oxygen Therapy Portable oxygen systems allow the patient to exercise, work, and travel 1/11/2023 302

Nutritional Therapy . Approximately 25% of patients with COPD are undernourished Coping Measures. 1/11/2023 303

Nursing process for the patient with COPD 1/11/2023 304

Nursing Assessment Determine smoking history , exposure history, positive family history of respiratory disease, onset of dyspnea. Note amount, color, and consistency of sputum. Inspect for use of accessory muscles of respiration and use of abdominal muscles during expiration; note increase of anteroposterior diameter of chest. Auscultate for decreased/absent breath sounds, crackles, decreased heart sounds. Determine level of dyspnea, how it compares to patient's baseline. Determine oxygen saturation at rest and with activity. 1/11/2023 305

Nursing Diagnoses Ineffective Airway Clearance related to bronchoconstriction, increased mucus production, ineffective cough, possible bronchopulmonary infection Ineffective Breathing Pattern related to chronic airflow limitation Risk for Infection related to compromised pulmonary function, retained secretions, and compromised defense mechanisms Impaired Gas Exchange related to chronic pulmonary obstruction, abnormalities due to destruction of alveolar capillary membrane Imbalanced Nutrition: Less Than Body Requirements related to increased work of breathing, air swallowing, drug effects with resultant wasting of respiratory and skeletal muscles Activity Intolerance related to compromised pulmonary function, resulting in shortness of breath and fatigue Disturbed Sleep Pattern related to hypoxemia and hypercapnia Ineffective Coping related to the stress of living with chronic disease, loss of independence 1/11/2023 306

Nursing Interventions Improving Airway Clearance Eliminate pulmonary irritants, particularly cigarette smoking. Cessation of smoking usually results in less pulmonary irritation, sputum production, and cough, and may slow progression of COPD. Keep patient's room as dust-free as possible. Add moisture (humidifier, vaporizer) to indoor environment, if appropriate. 1/11/2023 307

Administer bronchodilators to control bronchospasm and dyspnea and assist with raising sputum. Assess for adverse effects tremulousness , tachycardia, cardiac dysrhythmias, CNS stimulation, hypertension. Auscultate the chest after administration of aerosol bronchodilators to assess for improvement of aeration and reduction of adventitious breath sounds. Observe if patient has reduction in dyspnea. Monitor serum theophylline level, as ordered, to ensure therapeutic level and prevent toxicity. Use postural drainage positions to aid in clearance of secretions, if mucopurulent secretions are responsible for airway obstruction. 1/11/2023 308

Use controlled coughing . Keep secretions liquid. Encourage high level of fluid intake (8 to 10 glasses; 2 to 2.5 L] daily) within level of cardiac reserve. Give continuous aerolized sterile water or nebulized normal saline to humidify bronchial tree and liquefy sputum if appropriate. Avoid dairy products if these increase sputum production. 1/11/2023 309

Improving Breathing Pattern Teach and supervise breathing retraining exercises to strengthen diaphragm and muscles of expiration to decrease work of breathing . Teach diaphragmatic, lower costal, and abdominal breathing, using a slow and relaxed breathing pattern to reduce respiratory rate and decrease energy cost of breathing. Use pursed-lip breathing at intervals and during periods of dyspnea to control rate and depth of respiration and improve respiratory muscle coordination. Diaphragmatic and pursed-lip breathing should be practiced for 10 breaths four times daily before meals and before sleep. Inspiratory to expiratory ratio should be 1:2. 1/11/2023 310

Discuss and demonstrate relaxation exercises to reduce stress, tension, and anxiety. Encourage patient to assume position of comfort to decrease dyspnea. Positions might include leaning trunk forward with arms supported on a fixed object 1/11/2023 311

Controlling Infection Recognize early manifestations of respiratory infection increased dyspnea, fatigue; change in color, amount, and character of sputum; nervousness; irritability; low-grade fever. Obtain sputum for Gram stain and culture and sensitivity. Administer prescribed antimicrobials to control secondary bacterial infections in the bronchial tree, thus clearing the airways. 1/11/2023 312

Improving Gas Exchange Watch for and report excessive somnolence, restlessness, aggressiveness, anxiety, or confusion; central cyanosis; and shortness of breath at rest, which is commonly caused by acute respiratory insufficiency and may signal respiratory failure. Review ABG levels; record values on a flow sheet so comparisons can be made over time. Monitor oxygen saturation and give supplemental oxygen as ordered to correct hypoxemia in a controlled manner. Monitor and minimize CO 2 retention. Patients that experience CO 2 retention may need lower oxygen flow rates. Be prepared to assist with noninvasive ventilation or intubation and mechanical ventilation if acute respiratory failure and rapid CO 2 retention occur. 1/11/2023 313

Improving Nutrition Take nutritional history, weight, and anthropometric measurements. Encourage frequent small meals if patient is dyspneic ; even a small increase in abdominal contents may press on diaphragm and impede breathing. Encourage snacking on high-calorie, high-protein snacks, such as cheese, nuts. Offer liquid nutritional supplements to improve caloric intake and counteract weight loss. Avoid foods producing gas and abdominal discomfort. Employ good oral hygiene before meals to sharpen taste sensations. Encourage pursed-lip breathing between bites if patient is short of breath; rest after meals. Give supplemental oxygen while patient is eating to relieve dyspnea as directed. Monitor body weight. 1/11/2023 314

Increasing Activity Tolerance Reemphasize the importance of graded exercise and physical conditioning programs (enhances delivery of oxygen to tissues; allows a higher level of functioning with greater comfort). This may be part of a formalized pulmonary rehabilitation program or a referral to physical or occupational therapy. Discuss walking, stationary bicycling, swimming. Encourage use of portable oxygen system for ambulation for patients with hypoxemia. Encourage patient to carry out regular exercise program 3 to 7 days per week to increase physical endurance. Train patient in energy conservation techniques. 1/11/2023 315

Improving Sleep Patterns Maintain a balanced schedule of activity and rest. Use nocturnal oxygen therapy when appropriate. Avoid use of sedatives that may cause respiratory depression. 1/11/2023 316

Enhancing Coping Understand that the constant shortness of breath and fatigue make the patient irritable, apprehensive, anxious, and depressed, with feelings of helplessness and hopelessness. Assess the patient for reactive behaviors (anger, depression, acceptance). Demonstrate a positive and interested approach to the patient. Be a good listener and show that you care. Be sensitive to patient's fears, anxiety, and depression; may provide emotional relief and insight. Provide patient with control of as many aspects of care as possible. Strengthen the patient's self-image. Allow the patient to express feelings. Be aware that (within a controlled degree) the mechanisms of denial and repression may be useful defense mechanisms. Be aware that sexual dysfunction is common in patients with COPD. Encourage discussion of concerns and fears, and clarify misunderstandings. Encourage patient to use a bronchodilator and secretion clearance techniques before sexual activity, plan for sexual relations at time of day when patient has highest level of energy, use supplemental oxygen if needed, and consider alternative displays of affection to loved one. 1/11/2023 317

Bronchiectasis Bronchiectasis is a chronic, irreversible dilation of the bronchi and bronchioles . caused by a variety of conditions, including : • Airway obstruction • Diffuse airway injury • Pulmonary infections and obstruction of the bronchus or complications of long-term pulmonary infections • Genetic disorders such as cystic fibrosis • Abnormal host defense ( eg , ciliary dyskinesia or humoral immunodeficiency) • Idiopathic causes 1/11/2023 318

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