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Paranasal sinuses
• within 4 skull bones (frontal, ethmoid, sphenoid, maxillary);
• drain into nasal cavity;
• lined with mucous membranes;
• reduce weight of skull;
• resonating chambers for speech.
Trachea (windpipe)
• Location = mediastinum; anterior to esophagus; extends from larynx to T5;
• Structure:
o Function = support against collapse; continue to warm, moisten & filter air;
o Lined by mucous membranes;
o Carina = point where trachea divides into right & left bronchus…highly sensitive and touching it causes coughing.
LOWER RESPIRATORY ORGANS
The lungs contain more than 300 million alveoli = Surface area the size of a tennis court
for gas exchange at one time!
Recall that the function of the respiratory system is to supply cells with oxygen and remove carbon dioxide. The three basic processes
are pulmonary ventilation, external respiration and internal respiration.
Anatomical Dead Space (VD) = volume of air that fills the space between the nose and the bronchioles; approximately
150 ml;
Tidal Volume (VT) = volume of air that enters the lungs during normal inspiration and leaves the lungs during normal
expiration; approximately 500 ml (of which 150 ml is VD);
Inspiratory Reserve Volume (IRV) = the amount of air the can be forcibly inhaled after a normal tidal expiration;
approximately 3000 ml;
Expiratory Reserve Volume (ERV) = the amount of air that can be forcibly exhaled after a normal tidal expiration;
approximately 1100 ml;
Vital Capacity (VC) = the maximum amount of air that can be exhaled after a maximum inhalation;
Residual Volume = amount of air that always remains in lungs =1200 ml;
EXTERNAL RESPIRATION:
Definition = the exchange of oxygen and carbon dioxide between the alveoli and lung blood capillaries.
The pressure of gas determines the rate at which it will diffuse from region to region (Dalton's Law).
o Air is a mixture of gases:
78% Nitrogen
21% Oxygen
0.04% Carbon Dioxide
o In a mixture of gases, the amount of pressure that each gas creates = partial pressure.
In air: O2 = 21%; PaO2 = 104 mm Hg
In air: CO2 = .04%; PaCO2 = 40 mm Hg
The partial pressure of a gas is directly related to the concentration of that gas in a mixture.
Diffusion of gases through the respiratory membrane proceeds from where a gas is at high partial pressure
to low partial pressure.
ALVEOLUS CAPILLARY
PaCO2 PaCO2
40 mmHg 45 mmHg
PaO2 PaO2
104 mmHg 40 mmHg
Therefore, CO2 will flow from lung capillary ----> alveolus & O2 will flow from alveolus ----> lung capillary.
o The rate of diffusion of gases also depends on a number of factors, including the following:
gas exchange surface area;
diffusion distance;
breathing rate and depth.
INTERNAL RESPIRATION
Definition = the exchange of oxygen and carbon dioxide between tissue blood capillaries and tissue cells.
o In tissue cell: PaCO2 = 45; PaO2 = 40;
CELL CAPILLARY
PaCO2 PaCO2
45 mmHg 40 mmHg
PaO2 PaO2
40 mmHg 95 mmHg
o Therefore, oxygen moves from the tissue capillary into the tissue cell and carbon dioxide moves from the tissue cell
into the tissue capillary.
Oxygen
o Oxygen is carried in the blood in two forms: dissolved and bound to hemoglobin.
Dissolved oxygen is called partial pressure or arterial tension (PaO2) expressed as mmHg
Bound oxygen is called oxygen saturation (SaO2) expressed as a percentage
• Oxygen binds with hemoglobin (Hb) in red blood cells to form oxyhemoglobin;
• A weak bond is formed so oxygen can be delivered (released) to tissues when needed.
• The release of oxygen from hemoglobin depends on many factors:
o Increases with high blood PaCO2; decreases with low blood PaCO2;
o Increases when low blood pH (acidosis); decreases when high blood pH (alkalosis);
o Increases when high blood temperature; decreases when low blood temperature.
• Carbon monoxide (CO) binds to hemoglobin more efficiently than oxygen.
o If the hemoglobin (that is suppose to bind with oxygen) is bound to CO, much less Hb is
available to bind and transport oxygen to the tissues; Hypoxia results.
Carbon Dioxide (CO2)
o CO2 is transported in 3 forms:
dissolved CO2= 7% (PaCO2)
carbaminohemoglobin=23%
bicarbonate ions= 70% (HCO3-)
o In tissues, CO2 is produced by cellular respiration.
This CO2 combines with H2O to form H2CO3 (carbonic acid) which then…
dissociates under the influence of carbonic anhydrase to release…
H+ and bicarbonate ion (HCO3-): CO2 + H2O <------> H2CO3 <-------> H+ + HCO3-
• Reaction is reversed in lungs & CO2 is expelled during expiration.
Assessment Values (Normals)
o ABG = arterial blood gases
pH = 7.35 – 7.45
PaO2 = 80 – 100 mmHg
SaO2 = >95%
PaCO2 = 35 – 45 mmHg
HCO3- = 22 – 26 mEq/L
o VBG = venous blood gases
pH = 7.34 – 7.37
VO2 = oxygen consumption
PvO2 = mixed venous oxygen tension = 38 – 42 mmHg
SvO2 = venous oxygen saturation = 60% – 80%
PvCO2 = mixed venous carbon dioxide tension = 44 – 46 mmHg
HCO3- = 24-30 mEq/L
o Oximetry = arterial oxygen saturation with pulse oximetry
SpO2 = >95%
• Less accurate when SpO2 is less than 70% or when hemoglobin variants are present.
• Motion, low perfusion, anemia, bright lights, IV dyes, thick acrylic nails, dark skin color also make
pulse ox less accurate
Filtration of air
o Nasal hairs
o Turbulence: change in airflow direction at nasopharynx and larynx
o Mucuous trapping
o Particle size greater than 5 um are usually removed before reaching alveoli
Mucociliary clearance
o Mucous is continually secreted
Rate approx. 100 ml per day by goblet cells and submucosal glands
Secretory immunoglobulin A (IgA) in mucous protects against viruses and bacteria
o Cilia move particles to mouth to be swallowed and destroyed by digestive enzymes
May be impaired by dehydration, smoking, high O2 concentrations, infection and drugs like atropine,
anesthetics, alcohol, cocaine, cystic fibrosis and chronic bronchitis.
Cough reflex
o Only effective in removing secretions above the subsegmental level (large/main airways)
o Lower secretions must be moved upward by mucociliary elevator
Reflex bronchoconstriction
o In response to inhalation of large amounts of irritating substances, bronchi constrict.
Alveolar macrophages
o Alveoli do not have cilia, but have macrophages instead.
o Rapidly phagocytize inhaled foreign particles like bacteria.
o Debris moved to the level of bronchioles forremoval by cilia or lymph system.
o Impaired by cigarettes
Exposure to pollutants, smoke, etc, increases the risk of developing respiratory illnesses.
Loss of cilia, thickening of mucus, and impaired macrophages increases the risk of infection as one ages.
Breathing becomes more difficult as one ages due to:
o calcified cartilage
o skeletal changes
o altered posture
o replacement of bronchiole smooth muscle by fibrous connective tissue.
Vital Capacity decreases with age.
DIAGNOSTIC STUDIES
Blood
o Hemoglobin (Hg) and hematocrit (Hct)
o ABGs
o Oximetry (SpO2 and SvO2)
Sputum Studies
o Expectoration
o Tracheal suction
o Bronchoscopy
o Observe for color, blood, volume, viscosity
Skin Tests
o Allergy testing and TB
o Intradermal injection of an antigen
o Look for induration and measure diameter in mm.
Radiologic Studies
o Chest X-Ray
o Computed tomography (CT) 3-D views
o Magnetic Resonance Imaging (MRI)
o Ventilation-Perfusion Scan
For diagnosis of pulmonary embolus
o Pulmonary Angiography
Confirmation of ambolus if lung scan is inconclusive
Also diagnoses congenital and acquired lesions of the pulmonary vessels
o Positron Emission Tomography (PET)
For benign vs. malignant solitary pulmonary nodules
Graphs glucose metabolism (increased in malignancies)
Endoscopic Exams
o Bronchoscopy
Visualization of bronchi with a fiberoptic tube.
• For biopsies
• To remove mucous plugs or foreign bodies
• Bronchoalveolar lavage (BAL): 30 mL of sterile saline injected through the scope and withdrawn to
examine for cells.
o BAL diagnoses Pneumocystis carinii pneumonia
o Mediastinoscopy
Inspects and biopsy of lymph nodes in mediastinal area
Lung Biopsy
o Specimens obtained by transbronchial (through bronchoscope tube) or open lung.
Thoracentesis
o Insertion of a needle through the chest wall into the pleural space to obtain specimens for diagnosis
Pulmonary Function Tests (PFTs)
o Measure lung volumes and airflow.
o Diagnose pulmonary disease
o Performed with a spirometer
Exercise Testing
o Walking on a treadmill while expired oxygen/carbon dioxide, respiratory rate, heart rate and rhythm are monitored.
o Timed walk measures exercise capacity.
UPPER RESPIRATORY PROBLEMS Chapter 26
Deviated Septum
Definition: A deflection of the normally straight nasal septum to one side that alters the passage of air.
Cause: Trauma to the nose or congenital disproportion (septum is not proportional to the size of the nose).
Signs/Symptoms: Variable. May experience obstruction to nasal breathing, nasal edema, dryness of nasal mucosa with
bleeding. Severely deviated septum may block drainage of mucous resulting in sinus infection.
Treatment: Allergy control or surgery (“nasal septoplasty”).
Nasal Fracture
Cause: Trauma to the nose or middle part of the face.
Signs/Symptoms: Unilateral fracture: little or no displacement
Bilateral fracture: (most common) nose looks flattened
Complex: Caused by powerful frontal blows which may also shatter frontal bones.
Inability to breathe through each side of the nose, edema, bleeding, hematoma, ecchymosis (bruising)
under one or both eyes. Internally, look for septal deviation, hemorrhage or clear drainage which may
be CSF.
Treatment: Maintain a patent airway, reduce edema with ice, prevent complications, provide emotional support,
realign fractured parts with surgery (rhinoplasty or septoplasty).
Rhinoplasty
Definition: Surgical reconstruction of the nose for cosmetic purposes or to improve airway function R/T trauma or
deformities.
Role of the Nurse: Pre-op: Assess patient’s expectations of surgery (actual or perceived alteration in body image). Inform
patient not to take aspirin or NSAIDs for 2 weeks to reduce the risk of bleeding. Post-op: Assess
respiratory status, pain, surgical site for hemorrhage/edema.
Epistaxis
Definition: Nosebleed. Occurs especially in children (usually anterior bleeding) and in elderly adults (usually
posterior bleeding).
Cause: Trauma, foreign bodies, nasal spray abuse, street drug use, anatomic malformation, allergic rhinitis or
tumors. Hypertension does not cause nosebleed, but it can make a nosebleed more difficult to control.
First Aid: Keep the patient quiet; place patient in a sitting position, leaning forward; apply direct pressure by
pinching the entire soft lower portion of the nose for 10 to 15 minutes; apply ice compresses to thenose
and have the patient suck on ice; partially insert a small gauze pad into the bleeding nostril and apply
pressure if bleeding continues; get medical assistance if bleeding does not stop.
Treatment: Application of vasoconstrictive agent, cauterization, anterior packing, posterior packing.
Role of the Nurse: Posterior packing predisposes patient to bacterial infection, is painful and may alter respiratory status
(especially in elderly). Monitor respiratory rate, heart rate/rhythm, oxygen saturation (pulse ox), LOC
and observe for signs of aspiration. Patient should receive a mild narcotic analgesic for pain and an
antibiotic effective against Staph. Home teaching includes: sneezing with an open mouth and
avoidance of aspiring-containing products/NSAIDS, vigorous nose blowing, strenuous activity, lifting and
straining for 4 to 6 weeks after discharge.
INFLAMMATION AND INFECTION OF NOSE AND SINUSES
Allergic Rhinitis
Definition: The reaction of the nasal mucosa to a specific allergen.
Cause: Seasonal: caused by pollen, flowers, grasses and occur in spring/fall; last several weeks while allergens
are high. Perennial: caused by specific environmental triggers like pet dander, dust mites, molds,
cockroaches; is present intermittently or constantly and symptoms resemble the common cold.
Signs/Symptoms: Nasal congestion; sneezing; itchy, watery eyes and nose; altered sense of smell; thin, watery nasal
discharge; turbinates appear pale, boggy and swollen and may obstruct sinus drainage resulting in
sinusitis. Headache, congestion, pressure, post-nasal drip, nasal polyps, snoring may result in chorinic
allergies.
Treatment: Identify and avoid triggers (keep a diary to track activities that precipitate an allergic reaction). Drug
therapy includes nasal sprays, antihistamines, decongestants, intranasal corticosteroid sprays and
cromolyn sprays. Omalizumad (Xolair) is being investigated as a monoclonal antibody to
immunoglobulin E (IgE) that prevents the allergic cascade response. Immunotherapy (allergy shots)
attempt to control allergies through frequent, small exposures to triggers with the goal of decreasing
sensitivity to the allergens.
Role of the Nurse: Alert patients using antihistamines that sedation is a major side effect of the first-generation drugs
(benadryl). Patients using nasal inhalers need careful instructions about proper use of the equipment.
Teach patients that nasal decongestant sprays can cause a rebound effect from prolonged use.
Influenza
Definition: “Flu”
Cause: Three groups of viruses (A, B & C, though C has little pathogenic effects)
Signs/Symptoms: Abrupt onset of cough, fever, and myalgia often accompanied by headache and sore throat. Other cold-
like symptoms may also appear. Symptoms of uncomplicated flu usually subside within 7 days. Some
experience weakness and lassitude, hyperactive airways and chronic cough that may persist for weeks
(older adults, especially).
Persons over 50; adults with chronic illness, cardiac or respiratory problems; nursing home residents;
people hospitalized in the past year; immunocompromised adults; women in 2nd or 3rd trimester of
pregnancy; and people with known exposure to the virus are all at significantly higher risk.
PNEUMONIA is the most common complication of flu.
Treatment: Vaccine is 70 to 90% effective in preventing flu when given in the fall (mid-Oct) before exposure occurs.
All people over 50 and all healthcare workers are encouraged to get vaccinated. Soreness at the
injection site is the only side effect of the vaccine (but vaccine is contraindicated in people allergic to
eggs). FluMist (a nasal vaccine) is available to adults under 49 years of age.
Primary treatment: Relieve symptoms and prevent secondary infections.
Rimantadine (Flumadine) or amantadine (Symmetrel) and antivirals used against influenza A. (Side
effects may include heartburn and hallucinations). Zanamivir (Relenza) and oseltamivir (Tamiflu) are
effective against influenza A and B. They prevent the virus from budding and spreading to other cells.
Start treatments within 2 days of symptoms to reduce duration and severity of flu infection.
Sinusitis
Definition: Infection of the sinuses occurring as a result of blockage to the ostia (sinus exit) by inflammation or
swelling of the mucosa.
Cause: Bacteria, viruses and fungi all may grow in the secretions trapped in the sinuses and cause infection.
Bacterial infection is most commonly Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella
catarrhalis. Viral infection follows upper respiratory infection when virus invades mucous membrane
and decreases ciliary action. Fungal sinusitis is uncommon and is usually only in debilitated and
immunocompromised patients. Forty percent of intubated patients contract nosocomial sinusitis.
Two forms: Acute and Chronic.
Acute: results from upper respiratory infection, allergies, swimming or dental manipulation.
Chronic: (a persistent infection) associated with allergies and nasal polyps.
Signs/Symptoms: Acute: Significant pain over affected sinus, purulent nasal drainage, nasal obstruction, congestion,
fever and malaise. Patient looks and feels sick. Mucosa appears hyperemic, swollen and tender.
Headaches may change in intensity with position change or when secretions drain.
Chronic: Difficult to diagnose because symptoms are non-specific. Patient rarely presents with fever.
Symptoms may mimic allergies. X-Ray/CT Scan may show sinuses filled with thick fluid. Nasal
endoscopy may be used to examine sinuses and obtain a drainage culture.
Asthma and sinusitis are closely linked for unknown reasons. Appropriate treatment of sinusitis may
reduce asthma symptoms.
Treatment: Most cases of sinusitis resolve on their own without treatment within 2 weeks.
Keep well-hydrated; irrigate the nose with salt water; take hot showers/use steam inhaler to loosen
secretions; monitor for temperature >100.4 F; use analgesics for pain, decongestants/expectorants for
symptoms and antibiotics for infection; administer nasal sprays correctly; do not smoke. Avoid first-
generation antihistamines (Benadryl) as they thicken secretions. Second-generation (non-drowsy)
antihistamines are effective in relieving symptoms.
Broad-spectrum antibiotics taken for 4 to 6 weeks may be required with chronic sinusitis R/T mixed
bacterial flora present in infection.
Antibiotics reduce by 50% incidence of clinical failure
• TMP/SMZ
• Cephalexin
• Cefuroxime
• Cefalor
• Quinolones
• Macrolides
Antibiotics and other drugs may not resolve condition and infection may worsen or recur, or infection may be
drug resistant.
Complications include Osteomyelitis and Mucocele. In elderly – any respiratory infection may lead to
pneumonia.
Unresolved sinusitis may need referral to a specialist (ENT)
NASAL/SINUS OBSTRUCTIONS
Polyps
Definition: Benign mucous membrane masses which appear as bluish, glossy projections in the nare. Can exceed
the size of a grape!
Cause: Form slowly in response to repeated inflammation of the sinus or nasal mucosa.
Signs/Symptoms: Nasal obstruction, nasal discharge (usually clear), and speech distortion.
Treatment: Removal with endoscopic or laser surgery (but recurrence is common). Topical or systemic
cortiocosteroids may slow polyp growth.
Role of the Nurse: Monitor patient for anxiety R/T fear of malignancy.
Foreign Bodies
Signs/Symptoms: Inorganic items (buttons, beads, etc.) may have no symptoms, may lie undetected and be accidentally
discovered upon examination. Organic items (wood, cotton, beans, peas, raisins, paper) produce a
local inflammatory response with nasal discharge which may become purulent and foul smelling.
Treatment: Remove item from nose through the route of entry. Sneezing with the opposite nostril closed may be
effective in assisting the removal of foreign bodies. Do NOT irrigate or push the item further into the
nose as this can cause aspiration and airway obstruction. If removal is not possible…see a health care
provider!
Acute Pharyngitis
Definition: An acute inflammation of the pharyngeal walls (including tonsils, palate and uvula).
Cause: 70% are nonspecified viral infections. 15% to 20% are bacterial “Strep throat” infections caused by
beta-hemolytic Streptococcus invasion. Fungal pharyngitis, especially candidiasis can develop with
prolonged use of antibiotics or inhaled corticosteroids (especially in immunosuppressed patients –
HIV/AIDS)
Signs/Symptoms: Range from “scratchy throat” to pain so severe that swallowing is impaired. Both viral and bacterial
appear as red, edematous pharynx with or without yellow patchy exudate. Appearance is not
diagnostic! Cultures/rapid strep antigen tests must be done to determine cause and therefore treatment
course. Irregular white patches suggest fungal infection (Candida albicans). Gray-white
pseudomembrane covering the oro/naso/laryngo pharynx and trachea indicates diphtheria.
Treatment: Washing hands may prevent infections! Goals are infection control, symptom relief and prevention of
secondary infection. Bacterial infections may be treated with antibiotics. Candida infections are treated
with nystatin (swish medicine in mouth as long as possible before swallowing).
Increase fluid intake; cool/bland liquids and gelatin are non-irritating. Avoid citrus juices which irritate.
Peritonsillar Abscess
Definition: A complication of acute pharyngitis or acute tonsillitis when bacterial infection invades one or both
tonsils.
Signs/Symptoms: Tonsil enlarge sufficiently to threaten airway patency; high fever; leukocytosis; chills.
Treatment: IV antibiotics, needle aspiration/incision to drain abscess and possibly an emergency tonsillectomy.
Airway Obstruction
Definition: Any mechanical impediment to the delivery of air to the lungs or to the absorption of oxygen in the
lungs. May be partial or complete. Complete obstruction is a medical emergency.
Cause: Aspiration of food or a foreign body; laryngeal edema following extubation; laryngeal or tracheal
stenosis; CNS depression; allergic reactions (anaphylactic).
Signs/Symptoms: Stridor, use of accessory muscles, suprasternal and intercostal retractions, wheezing, restlessness,
tachycardia and cyanosis.
Treatment: Prompt assessment is required as partial obstruction can quickly progress to complete obstruction.
Reestablish a patent airway (Heimlich’s maneuver), cricothyroidtomy (an emergency incision into the
larynx performed to open the airway in a person who is choking); endotracheal intubation and
tracheostomy. Unexplained or recurring symptoms need additional tests (chest XRay, pulmonary
function tests and bronchoscopy).
Tracheostomy
Definition: A tracheotomy is a surgical incision into the trachea for the purpose of establishing an airway. A
tracheostomy is the stoma (opening) that results from the tracheotomy.
Purpose: Bypass an upper airway obstruction; facilitate the removal of secretions; permit long-term mechanical
ventilation; permit oral intake and speech in the patient with long-term mechanical ventilation.
Advantages: Compared to endotracheal tubes, tracheostomies have less risk of long-term damage to the airway; are
more comfortable for patient because no tube is in the mouth; allows the patient to eat and speak; and
is more secure so mobility for the patient is enhanced.
Role of the Nurse: Care of the patient with a tracheostomy involves suctioning the airway to remove secretions; cleaning
around the stoma; changing tracheostomy ties; inner cannula care; continuously assessing the risk of
aspiration and educating the patient about the care of his/her tracheostomy.
Laryngeal Polyps
Definition: Growths on the vocal cords.
Cause: Vocal abuse or irritation (intubation, cigarettes).
Signs/Symptoms: Hoarseness
Treatment: Surgical removal of large polyps that cause stridor and dyspnea may be required. Polyps are usually
benign, but may later become malignant.
Head/Neck Cancer
Definition: Malignant tumors, typically squamous cell in origin, that arise from mucosal surfaces of the paranasal
sinuses, oral cavity and naso/oropharynx and larynx.
Cause: Though this type of cancer is rare in the general population, 90% of cases occur in adults 50 years or
older after prolonged use of tobacco and alcohol. Twice as many males as females are affected.
Signs/Symptoms: Disability is great because of potential loss of voice, facial disfigurement and social consequences.
Early signs/symptoms vary with tumor location:
Oral cavity cancer may start as a painless growth in the mouth or ulcer that does not heal. Pain is
a late symptom that may be aggravated by acidic food.
-pharynx and supraglottic larynx cancers rarely produce early symptoms and are diagnosed in late
stages when patient complains of persistent unilateral sore throat or ear pain.
Laryngeal cancer may have hoarseness as an early symptom.
Lumps in the neck or hoarseness that lasts longer than 2 weeks requires a medical evaluation.
Late signs/symptoms are easily detected: pain, dysphagia, decreased mobility of tongue, airway
obstruction, cranial nerve neuropathy.
Diagnosis: Thorough examination of oral cavity is required, including under the tongue and dentures; The floor of
the mouth, tongue and lymph nodes in the neck should be palpated. Look for thickening of the normally
soft and pliable oral mucosa. Leukoplakia (white patches) or erythroplakia (red patches) may be seen
and should be biopsied.
Indirect laryngoscopy and/or flexible nasopharyngoscope may be used to visually inspect the larynx and
vocal cords for lesions and tissue mobility. CT scans or MRIs may be used to detect local/regional
spread of cancer. Typically, multiple biopsy specimens are required to determine the extent of the
disease.
TNM Staging is used to classify the disease process. (T) = tumor size; (N) = number/location of
involved nodes and (M) = extent of metastasis. TNM is classified in stages I to IV and stage guides the
treatment.
Treatment: Stage I or II may undergo radiation therapy or surgery with the goal of cure.
Laryngeal cancer:
Radiation
• Radiation effectively cures early vocal cord lesions without damaging the voice.
o Brachytherapy: Thin, hollow needles are inserted into the tumor area and radioactive
iridium seeds are placed in the needles. This delivers a concentrated, but localized,
dose of radiation to the tumor but does not affect surrounding tissues. May be used
alone or in conjunction with external radiation.
Surgical Interventions:
• Hemilaryngectomy: removal of one vocal cord or part of a cord and requires a temporary
tracheostomy. Voice is preserved but quality is hoarse and breathy.
• Supraglottic laryngectomy: removal of structures above the true vocal cords (false cords and
epiglottis). Patient is left with high risk of aspiration and requires a temporary tracheostomy.
Voice is preserved, but quality is hoarse and breathy.
• Total laryngectomy: removal of entire larynx and pre-epiglottic region with permanent
tracheostomy.
• Neck dissection: often accompany total laryngectomies and involves excision of lymph nodes
and lymph channels (to reduce risk of spreading disase).
o Radical neck dissection: Wide excision of nodes and lymph channels, and includes
removal or transaction of sternocleidomastoid muscles (and other neck muscles),
internal jugular vein, mandible, submaxillary gland, part of the thyroid/parathyroid
glands and the spinal accessory nerve. Usually is only performed on one side of the
neck.
o Modified neck dissection: Spares as many structures as possible to limit
disfigurement and functional loss. Removes major cervical lymph vessels but spares
nerves, veins and muscles when possible. When cancer lesion is midline, bilateral
neck dissections are required, but a modified procedure will be performed on at least
one side.
o Nutrition Therapy for Neck Dissections
Parenteral fluids for 24-48 hours. Tube feedings via NG, nasointestinal or
gastrostomy tube may be required. (Watch for intolerance of feeding—
nausea/vomiting/diarrhea/distention).
When patient can swallow, watch for choking and aspiration.
Anticipate swallowing issues. Teach supraglottic swallow to minimize
aspiration risks.
Avoid thin, watery fluids, instead use non-pourable pureed foods of foods
thickened with an agent (thicker foods allow more control in swallowing).
Give antiemetics and analgesias before meals to reduce nausea and mouth
pain.
Always feed with head of bed elevated.
Planning: Goals: a patent airway; no spread of cancer; no complications related to therapy; adequate nutritional
intake; minimal to no pain; ability to communicate; acceptable body image.
Interventions Immediately after surgery: maintain patent airway; place patient in semi-Fowler’s position (decrease
edema); monitor vital signs for hemorrhage and respiratory compromise; use would suction system as
needed.
Radiation therapy: Dry mouth may be treated with increased fluid intake, sugarless gum, sugarless
candy, nonalcoholic mouth wash, artificial saliva, oral hygiene. Stomatitis (dry lips at the corners of
mouth) may be treated with water/hydrogen peroxide (3:1 ratio) rinse, or baking soda and water (1t to 8
oz of water) to clean/soothe irritated tissue. Avoid commercial mouthwash and hot/spicy foods. Altered
skin integrity is common.
Teach patient about changes in speech and alternate ways to communicate (prostheses, esophageal
speech method). Teach about stoma care.
Monitor patient for signs of depression (loss of function, disfigurement, body image and sexuality
issues.)
Prognosis: Overall, the cure rate for head/neck cancer is low for advanced stages, despite surgical and radiation
interventions. Metastatic cancer is painful and leaves patients in a severely debilitated state.
LOWER RESPIRATORY PROBLEMS Chapter 27
Acute Bronchitis
Definition: Inflammation of the bronchi in the lower respiratory tract usually due to infection. One of the most
common conditions seen in primary care.
Cause: Usually occurs as a complication of an upper respiratory tract infection brought on by a virus
(rhinovirus, influenza, corona virus, respiratory synctial virus (RSV), adenovirus, influenza A and B,
parainfluenza).
Bacterial infections are also common
• Smokers usually infected with Strep pneumoniae and Haemophilus influenzae;
• Impressive constitutional symptoms (shaking chills, high fever, fatigue, sweats, muscle
aches)…
o Suggest influenza
• Recurrent episodes of acute bronchitis…
o Concern for HIV infection
When symptoms are severe, chest x-rays can differentiate acute bronchitis from pneumonia (acute
bronchitis has no evidence of consolidation or infiltrates).
Treatment: Usually self-limiting; treatment is supportive…
• Fluids
• Rest
• Anti-inflammatory agents
• Antiviral medications
• Cough suppressant or bronchodilators for symptomatic treatment of nocturnal
cough/wheezing
• Other symptom relief to reduce complaints
Pharmacotherapy
• Antibiotics are not usually prescribed unless person has prolonged infection, is a smoker
or has COPD.
• No proven value in using antibiotics in acute bronchitis
• Increases medical costs
• Fosters drug resistance
• Contributes to drug toxicity
• When prescribed, the drug of choice is a broad-spectrum antibiotic for multi-flora
infections.
o In acute exacerbation of chronic bronchitis, early intervention with antibiotics
can reduce hospitalizations and decrease risk of relapse. If untreated, acute
exacerbation of chronic bronchitis can lead to respiratory failure.
• For Flu: amantadine or rimantadine within 48 hours may help
• For wheezing: albuterol inhaler
Pneumonia
Definition: An acute inflammation of the lung parenchyma that commonly impairs gas exchange. Bacterial
pneumonia is the leading cause of death in debilitated patients.
Cause: Pneumonia may be viral, bacterial, fungal, protozoal (parasitic), or chemical in origin.
• Primary pneumonia results from inhalation or aspiration of a pathogen;
• Secondary pneumonia may follow lung damage from noxious chemicals or other insults,
or may result from hematogenous spread of bacteria (bacteria in the blood).
• Aspiration pneumonia results from inhalation of foreign matter (vomitus, food particles)
into the bronchi.
• Pneumonia can also be transmitted by direct contact with contaminated equipment
(suction catheters, bronchoscopes).
Bacterial pneumonia:
• Infection initially triggers alveolar inflammation and edema, which produces an area of low
ventilation with normal perfusion.
• Capillaries become engorged with blood, causing stasis.
• As alveolocapillary membrane breaks down, alveoli fill with blood and exudate, resulting in
atelectasis (lung collapse)
• Lungs look heavy and liver-like.
Viral pneumonia:
• The virus first attacks bronchiolar epithelial cells, which causes interstitial inflammation
and desquamation.
• The virus also invades bronchial mucous glands and goblet cells.
• It spreads to the alveoli, which fill with blood and fluid.
Aspiration pneumonia:
• Inhalation of gastric juices or hydrocarbons trigger inflammation and inactivates surfactant
over a large area.
• Decreased surfactant leads to alveolar collapse.
• Acidic gastric juices may damage the airways and alveoli. Particles containing aspirated
gastric juices may obstruct the airways and reduce airflow, leading to secondary bacterial
pneumonia.
Risk Factors: Factors predisposing to pneumonia:
• Aging
• Air pollution
• Altered consciousness (alcoholism, head injury, seizures, anesthesia, drug overdose,
stroke)
• Altered oropharyngeal flora
• Bed rest/prolonged immobility
• Chronic disease (COPD, diabetes mellitus, heart disease, cancer, end-stage renal
disease)
• Debilitating illness
• HIV
• Immunosuppresive drugs (corticosteroids, cancer chemotherapy, organ transplant)
• Inhalation or aspiration of noxious substances
• Intestinal and gastric feedings
• Malnutrition
• Smoking
• Tracheal intubation
• Upper respiratory tract infection
Complications: Pneumonia in an otherwise healthy adult usually resolves without complications. However, in
compromised patients, complications include…
• Pleurisy – inflammation of the pleura
• Pleural effusion – usually effusion is sterile and reabsorbed in 1 to 2 weeks
• Atelectasis – collapsed, airless alveoli in part of one lobe. Usually clears with effective
coughing and deep breathing
• Delayed resolution – results from persistent infection with residual consolidation (elderly,
malnourished, alcoholic or COPD at highest risk)
• Lung abscess – usually S. aureus and Gram-negative pneumonias
• Empyema – accumulation of purulent exudate in the pleural cavity (needs antibiotics and
drainage via chest tube or surgery)
• Pericarditis – spread of infection from lungs to heart lining
• Arthritis – systemic spread of infection affects joints
• Meningitis – can be caused by S. pneumoniae. Look for disorientation, confusion,
somnolent symptoms.
• Endocarditis – spread of infection to valves of the heart.
Diagnosis: Chest x-ray…
• Lobar/segmental consolidation = bacterial cause, usually Strep pneumoniae or Klebsiella
Tuberculosis
Definition: An infectious disease caused by Mycobacterium tuberculosis. Usually involves the lungs, but may
occur in the larynx, kidneys, bones, adrenal glands, lymph nodes and meninges and can be
disseminated throughout the body.
• TB kills more people worldwide than any other infectious disease.
• In the late 1940s, streptomycin and isoniazid (INH) brought about a dramatic decrease in
TB prevalence.
• Between 1985 and 1992, there was a significant increase in TB prevalence due to...
o HIV infection
o Multidrug-resistant (MDR) strains of M. tuberculosis
o Poor compliance with drug therapy
o Treatment failure
o Poor follow-up treatment
o Decreased vigilance in treating patients
• Prevalence has again decreased since 1993 due to improvements in TB control programs.
Cause: M. tuberculosis is a gram-positive, acid-fast bacillus that is spread from person to person via
airborne droplets, which are produced when the infected individual with pulmonary or laryngeal TB
coughs, sneezes, speaks or sings.
Risk factors:
• Poor, under-served minorities
• Homeless people
• Residents of inner-city neighborhoods
• Foreign-born people
• Older adults
• Institutionalized people
• IV/injection drug users
• Socioeconomically disadvantaged
• Medically underserved of all races
• Immunosuppressed people (HIV, cancer, organ transplant)
• Native American population (Arizona, New Mexico)
• Mexican border
• Health care workers
TB is not highly infectious and transmission usually requires close, frequent or prolonged exposure.
Pathophysiology:
o Bacilli are inhaled and implant in bronchioles or alveoli
o After implantation, bacilli multiply with no initial resistance from host
o Bacilli are engulfed by phagocytes
o Continue to multiply within the phagocytes
o Phagocytes/macrophages spread the bacilli through the lymphatic system into the blood
stream before a cellular immune response can be activated
o Kidneys, epiphyses of bones, cerebral cortex and adrenal glands are target sites
of TB
o Eventually cellular immunity limits further spread of infection.
o A characteristic tissue reaction called epithelioid cell granuloma results from
cellular immune reaction
Granuloma is result of fusion of the infiltrating macrophages
Granuloma is surrounded by lymphocytes within 10 to 20 days
Central part of granuloma lesion is called Ghon tubercle which
undergoes necrosis characterized by a cheesy appearance named
caseous necrosis.
The lesion may also undergo liquefactive necrosis in which the liquefied
remains of the lesion drains into connecting bronchi and produces a
cavity.
The tubercular material may enter the tracheobronchial system, allowing
airborne transmission of infectious particles.
o Healing of lesion involves resolution, fibrosis and calcification.
The granulation tissue surrounding the lesion may become more fibrous
and form a collagenous scar around the tubercle. A Ghon complex is
formed, consisting of the Ghon tubercle and regional lymph nodes.
Calcified Ghon complexes may be seen on chest x-ray.
o The disease enters a latent phase in which it may persist without clinical
symptoms.
o If the initial immune response is not adequate, control of the organisms is not
maintained and clinical illness results.
People at risk for clinical illness are usually immunosuppressed…
• HIV infection
• Cancer with chemotherapy
• Long-term corticosteroid use
• Diabetes mellitus
Signs/Symptoms: Early Stage:
• Usually symptom-free; many cases are found incidentally with routine chest x-ray,
especially in older adults
• Systemic manifestations…
o Fatigue
o Malaise
o Anorexia
o Weight loss
o Low-grade fever
o Night sweats
• Pulmonary manifestations…
o Frequent cough that produces mucoid or mucopurulent sputum
o Dyspnea is unusual
o Chest pain characterized as dull or tight
o Hemoptysis is uncommon and is usually associated with advanced stages
Acute Onset:
• High fever
• Chills
• Generalized flu-like symptoms
• Pleuritic pain
• Productive cough
Complications: Complications of TB include…
• Miliary (Hematogenous) TB
o A necrotic Ghon complex erodes through a blood vessel and large numbers of
organisms invade the blood stream and spread throughout the body.
• Patient may be acutely ill with fever, dyspnea and cyanosis or…
• Chronically ill with systemic manifestations of weight loss, fever and GI
disturbance.
• Hepatomegaly, splenomegaly and generalized lymphadenopathy may
be present.
• Pleural Effusion and Empyema
o Release of caseous material into the pleural space triggers an inflammatory
reaction and a pleural exudate of protein-rich fluid.
o Dry pleurisy may result from a superficial tuberculosis lesion involving the pleura.
o Empyema is less common but may occur from large numbers of organisms
spilling into the pleural space from a ruptured cavity.
• Tuberculosis Pneumonia
o Results when large amounts of bacilli spill from the liquefied necrotic lesion into
the lung or lymph nodes.
o Symptoms resemble bacterial pneumonia…
• Chills
• Fever
• Productive cough
• Pleuritic pain
• Leukocytosis
• Other Organ Involvement
o Meninges
o Bone and joint tissue
o Kidneys
o Adrenal glands
o Lymph nodes
o Female and male genital tracts
Diagnosis: Classification of TB
o Class 0: No TB exposure
o Class 1: TB exposure, no infection (negative skin test)
o Class 2: Latent TB infection, no disease (positive skin test; other tests negative)
o Class 3: TB clinically active (positive skin test; other tests positive; symptomatic of TB)
o Class 4: TB, not clinically active (positive skin test; documented history of disease; x-
ray shows evidence of past infection; bacteriology tests negative; no symptoms)
o Class 5: TB Suspect (diagnosis pending…no more than 3 months in this class)
Tuberculin Skin Testing
o Antigen/Antibody reaction test…uses purified protein derivative (PPD) of tuberculin to
detect TB antibodies from a previous immune response.
o Once acquired, sensitivity to TB persists throughout life.
o Reaction of >5 mm induration is positive for patients with…
o Recent close contact with person diagnosed with infectious TB
o Chest x-ray with fibrotic lesions likely to be healed TB
o Known or suspected HIV infection
o Organ transplants and other immunosuppressive conditions
o Reaction of >10 mm induration is positive for patients…
o With other medical risk factors known to substantially increase risk of TB once
infection has occurred (diabetes, renal disease, cancer)
o Who recently immigrated from (in past 5 years) from areas of high prevalence
o Who are medically under-served or homeless
o Who reside in long-term care facilities and prisons
o Who use IV drugs
o Who are health care workers
o Who are low risk for TB
o Reaction of >15 mm induration is positive for all others at low risk.
Chest X-ray
o It is not possible to make a diagnosis of TB solely on the basis of a chest x-ray.
o Chest x-ray in TB patient most commonly shows multinodular lymph node involvement
with cavitation in the upper lobes of the lungs.
o Calcification of lesions occurs within several years of infection.
Bacteriologic Studies
o True diagnosis can only be made by demonstrating the presence of tubercle bacilli.
o Stained sputum smear for acid-fast bacilli is usually the first bacteriologic evidence of
infection.
o Three consecutive sputum specimens collected on different days are tested.
o Gastric washes, cerebrospinal fluid and pus from an abscess can all be stained and
tested.
o Nucleic acid amplification (NAA) is a new, rapid diagnostic test for TB. Results are
available in a few hours, but the NAA test does not replace routine sputum smears and
cultures.
Treatment: Outpatient Treatment
o Patient may continue to work and maintain lifestyle
o Hospitalization is only for diagnosis or for severe illness, adverse drug reactions or
treatment failures.
Drug Therapy
o Active Disease
o Multidrug-resistant TB occurs when resistance develops to two or more anti-TB
drugs
o Treatment usually consists of a combination of at least four drugs.
o Five primary drugs currently used are:
Isoniazid (INH)
Rifampin (Rifamate)
Pyrazinamide
Streptomycin
Ethambutol (Myambutol)
o Fixed-dose combo drugs (INH/rifampin and INH/rifampin/pyrazinamide) are
available and may enhance compliance to treatment
o HIV patients on antiretroviral drugs cannot take rifampin because it impairs the
effectiveness of the antiretroviral drug.
o Newer drugs include the quinolones (ciprofloxacin/Cipro) and rifapentine (Priftin).
o Therapy must be continued for 6 to 9 months.
o Drug regimens should be adapted to the resistance pattern evident from sputum
culture.
o Monitor the effectiveness of drugs and the development of toxic side effects.
o Test sputum samples weekly and then monthly to assess effectiveness.
Regimen is considered effective if the patient converts to a negative TB
sputum status.
o Follow-up care ensures adherence to the treatment regimen with Directly
Observed Therapy (DOT) with patients known to be at risk for noncompliance.
o Teaching patients about the side effects of these drugs and when to seek prompt
medical attention is critical.
o The major side effect of INH, rifampin and pyrazinamide is HEPATITIS.
Monitor liver function tests regularly.
Latent Infections
o Latent TB Infection (LTBI) occurs when an individual become infected but does
not become ill.
o Drug therapy can be used to prevent a TB infection from developing into a
clinical disease.
o INH administered orally once daily for 6 to 9 months can prevent illness.
HIV patients and those with fibrotic lesions on chest X-ray take INH for
full 9 months.
Vaccine
o Immunization with bacilli Calmette-Guerin (BCG) vaccine prevents.
o Is currently in use in many parts of the world.
o The PPD skin test of vaccinated individuals results in an induration of less than
10 mm. Therefore a “positive” TB test for vaccinated indivduals is defined as “an
increase in induration by 10 mm from a previous PPD test.” (American Thoracic
Society)
Role of Nurse: Goals:
o Patient will comply with therapeutic regimen
o Patient will have no recurrence of disease
o Patient will have normal pulmonary function
o Patient will take appropriate measures to prevent the spread of disease.
Interventions:
o Assess symptomatic patient for exposure to persons with TB.
o Patients strongly suspected of having TB should…
o Be placed on respiratory isolation
o Receive four-drug therapy
o Receive an immediate medical work-up, including chest x-ray, sputum smear and
culture
o Use a negative pressure isolation room that offers six or more exchanges per
hour to isolate patient.
o Teach patient to cover the nose and mouth with paper tissue every time he or she coughs,
sneezes or produces sputum. The tissues should be burned, flushed down the toilet or
thrown into a paper bag and disposed of with the trash.
o Instruct the patient about certain factors that could reactivate TB such as
immunosuppressive therapy, malignancy and prolonged debilitation.
Atypical Mycobacteria
Definition and Cause: A pulmonary disease that closely resembles TB but caused by atypical acid-fast mycobacteria.
o Is indistinguishable from TB except by bacteriologic culture.
o These organisms are a common cause of opportunistic infections in HIV patients.
o Treatment depends on specific organsism, but many of the drugs used in TB are effective
in atypical mycobacteria.
Pulmonary Fungal Infections
Definition and Cause: Organisms include…
o Histoplasma capsulatum
o Coccidioides immitis
o Blastomyces dermatitidis
o Cryptococcus neoformans
o Aspergillus niger or A. fumigatus
o Candida albicans
o Actinomyces Israeli
o Nocardia asteroides
Found most frequently in seriously ill patients being treated with corticosteroids, antineoplastics,
immunosuppressive drugs and multiple antibiotics and in patients with AIDS and cystic fibrosis.
• Fungi not transmitted person to person so patient does not have to be placed in isolation.
• Signs and symptoms are similar to those of bacterial pneumonia
• Identification in sputum specimen or other body fluid is best diagnostic indicator.
Treatment Amphotericin B is the drug most widely used in treating serious systemic fungal infections.
• Must be given intravenously to achieve adequate blood and tissue levels because it is
poorly absorbed from the GI tract.
• Is considered toxic with many possible side effects
o Hypersensitivity reactions
o Fever
o Chills
o Malaise
o Nausea/vomiting
o Thromobphlebitis at the injection site
o Abnormal renal function
o Avoid side effects by…
Pre-medicating with an anti-inflammatory of diphenhydramine
(Benadryl) one hour before infusion
Include small amount of hydrocortisone in the infusion to decrease
irritation of the veins
Monitor renal function
Ensure adequate hydration
• Is incompatible with most other drugs
• Administered every other day after an initial period of several weeks of daily therapy.
• Total treatment duration may range from 4 to 12 weeks.
Other oral drugs used to treat fungal infections include:
o Oral imidazole and triazole compounds with antifungal activity (ketoconazole,
fluconazole).
o May be used as alternative to amphotericin B.
Bronchiectasis
Definition: A permanent, abnormal dilation of one or more large bronchi resulting from destruction of the
elastic and muscular structures of the bronchial wall from bacterial infections.
o Two types:
o Saccular bronchiectasis occurs in large bronchi; characterized by cavity-like
dilations which end in large sacs.
o Cylindric bronchiectasis occurs in medium-sized bronchi that are mildly to
moderately dilated.
Cause: Almost all are associated with bacterial infections, including S. aureus, Klebsiella and anaerobes.
Viruses such as adenovirus and influenza can also cause bronchiectasis.
o Infections cause the bronchial walls to weaken, and pockets of infection begin to form.
When the walls of the bronchial system are injured, the mucociliary mechanism is
damaged allowing bacteria and mucus to accumulate within the pockets.
o Mycobacteria avium-intracellulare presents a new threat because it can progress to
bronchiectasis.
Signs/Symptoms: Hallmark is persistent or recurrent cough with production of greater than 20 mL of purulent sputum
per day.
o Cough is paroxysmal and is stimulated with position change
o Copious (may be blood-streaked) sputum
o Exertional dyspnea
o Fatigue
o Weight loss
o Anorexia
o Fetid breath
o Crackles, rhonchi and wheezing may be heard
o Sinusitis frequently accompanies diffuse bronchiectasis
o Advanced, widespread bronchiectasis symptoms are generalized wheezing, digital
clubbing and cor pulmonale.
Diagnosis: Diagnostic studies…
• Chest x-rays show streaky infiltrates or may be normal;
Lung Abscess
Definition: A pus-containing lesion of the lung parenchyma that gives rise to a cavity. The cavity is formed by
necrosis of the lung tissue.
Cause: Caused by aspiration of material from the oral cavity (gingival crevices) into the lungs.
Organisms include enteric gram-negative organisms (Klebsiella), S. aureus and anaerobic bacilli.
May also be caused by a lung infarct secondary to pulmonary embolism, malignant growth, TB and
various parasitic and fungal diseases of the lung.
Risk factors:
• Alcoholism
• Seizure disorders
• Neuromuscular diseases
• Drug overdose
• General anesthesia
• Stroke
Signs/Symptoms: Onset is usually insidious, especially with anaerobic organisms. Aerobic organisms cause a more
acute onset. Symptoms include…
• Cough-producing purulent sputum (often dark brown) this is foul smelling and foul tasting
• Hemoptysis is common, especially when abscess ruptures into bronchus
• Fever
• Chills
• Prostration
• Pleuritic pain
• Dyspnea
• Cough
• Weight loss
• Dullness to percussion over affected areas
• Bronchial breath sounds to the periphery
• Crackles in later stages of condition
• Complications include…
o Chronic pulmonary abscess
o Bronchiectasis
o Brain abscess as a result of hematogenous spread of infection
o Broncopleural fistula
o Empyema from abscess perforation into the pleural cavity
Diagnosis: Chest x-ray reveals solitary cavitary lesion with fluid.
CT scanning confirms x-ray findings.
Lung abscesses do not require assisted drainage as long as there is drainage via the bronchus.
Routine sputum cultures are not reliable.
Pleural fluid and blood cultures may help identify bacteria.
Bronchoscopy may assist in draining abscess or in factors that suggest an underlying malignancy.
Treatment: Antibiotics given for a prolonged period (2 to 4 months) are usually the primary method of
treatment.
• Penicillin was once standard, but anaerobic bacteria produce beta-lactamase that resist
effects of penicillin.
• Clindamycin (Cleocin) is the new standard of treatment.
o Putrid lung abscesses show improvement with decreased fever within 3 to 4 days
of beginning clindamycin.
• Surgery is rarely indicated, but may be needed in reinfection of a large cavitary lesion.
o Usually lobectomy or pneumonectomy.
Role of Nurse: Interventions…
• Chest physiotherapy and postural drainage are sometimes used to drain abscesses
located in the lower or posterior portions of the lung.
• Teach patient to complete entire course of antibiotics.
• Teach patient to cough effectively.
• Frequent (every 2 to 3 hours) mouth care is needed to relieve the foul smelling odor and
taste from the sputum.
o Use diluted hydrogen peroxide and mouthwash
• Rest, good nutrition and adequate fluid intake are supportive interventions.
Trauma/Thoracic Injuries:
• Blunt trauma
o Occurs when the body is struck by a blunt object (like a steering wheel)
o Contrecoup trauma
A type of blunt trauma caused by the impact of parts of the body against other objects (organs bouncing
around inside the body)
• Penetrating trauma
o Occurs when a foreign body impales or passes through the body tissues (like gunshot wounds, stabbings)
Pneumothorax
Definition: Air in pleural space, causes collapse of lung
• Closed Pneumothorax
o No external wound
o Often spontaneous caused by rupture of blebs (most commonly in underweight male
cigarette smokers 20 – 40 years of age)
o Other causes:
Mechanical ventilation
Insertion of subclavian catheter
Perforation of esophagus
Broken ribs
Ruptured blebs or bullae in patient with COPD
• Open Pneumothorax
o Caused by an opening in the chest wall (penetrating injury)
o Should be covered with a vented dressing (secured on three sides with fourth side left
untapped)
o If object of penetration is present…do not remove it…secure it with bulky dressings.
• Tension Pneumothorax (open or closed)
o Air accumulates rapidly in pleural space increasing intrapleural pressure with resultant
pressure on heart and great vessels.
o Occurs in mechanical ventilation and resuscitative efforts or when chest tubes are
clamped or obstructed
o Medical emergency leading to death from inadequate cardiac output
o May be relieved with large-bore needle insertion into chest wall to relieve trapped air
• Hemothorax (blood in pleural space)
o Caused by trauma, lung malignancy, complications of anticoagulant therapy, pulmonary
embolus and tearing of pleural adhesions.
• Chylothorax (lymph fluid in pleural space)
o Caused by a leak in the thoracic duct from trauma, surgical procedures, malignancy.
o Chest drainage, bowel rest, and total parenteral nutrition may be used for treatment
o Surgery and Pleurodesis (artificial production of adhesions between the parietal and
visceral pleura) are options for treatment
Signs/Symptoms: If small:
• mild tachycardia and dyspnea
If large:
• respiratory distress;
• shallow, rapid respirations, dyspnea, and air hunger;
• chest pain;
• cough with or without hemoptysis;
• No breath sounds over affected area
If tension pneumothorax:
• severe respiratory distress;
• tachycardia;
• hypotension;
• mediastinal displacement and trachea shifts to the unaffected side.
Fractured Ribs
Definition: Most common type of chest injury resulting from trauma.
• Ribs 5 through 10 are most commonly affected because they are least protected.
• Splintered or displaced ribs can damage the pleura and lungs.
Signs/Symptoms: Signs of fractured ribs include…
• Pain at site of injury (especially on inspiration)
• Bracing and splinting of affected area
• Shallow breathing
• Atelectasis
Treatment: Goals of treatment are decrease pain and promote good chest expansion.
• Intercostal nerve blocks with local anesthesia
o Lasts hours to days
o May need to be repeated
• Do NOT strap the chest or use a binder…it reduces lung expansion and may lead to
atelectasis
Flail Chest
Definition/Cause: Instability of chest wall caused by multiple rib fractures.
Sign/Symptoms: The affected (flail) area will move paradoxically to the intact portion of the chest during respiration.
• During inspiration, flail area gets sucked inward
• During expiration, flail area bulges outward
• Prevents adequate ventilation and leads to hypoxemia
• Flail chest is apparent in an unconscious patient; but a conscious patient will brace/splint
the affected side preventing observation.
o Rapid, shallow respirations
o Tachycardia
o Poor air movement
o Asymmetric and uncoordinated movement of the thorax
Diagnosis: Palpation or respiratory movements; crepitus of the rib(s); chest x-ray and ABGs assist in
diagnosis.
Treatment: The definitive therapy is to reexpand the lung and ensure adequate oxygenation.
• Assist with ventilation
• Provide humidified oxygen
• Administer crystalloid IV solutions
• Short duration of intubation and mechanical ventilation
• Positive End-Expiratory Pressure (PEEP) used with mechanical ventilation
Pleural Effusion
Definition: Pleural effusion is a collection of fluid in the pleural space.
Types & Causes: Types:
• Transudate (hydrothorax)
o Occurs in noninflammatory conditions and is an accumulation of protein-poor,
cell-poor fluid.
o Caused by…
Increased hydrostatic pressure (as in CHF)
Decreased oncotic pressure (as in hypoalbuminemia from liver and
renal disease)
o Thoracentesis reveals clear, pale yellow fluid
• Exudative
o Occurs in inflammatory conditions and is an accumulation of fluid and cells.
o Is secondary to conditions such as pulmonary malignancies, pulmonary
infections, pulmonary embolization and GI disease (pancreatic disease,
esophageal perforation)
o Thoracentesis reveals high protein fluid that is dark yellow or amber
• Empyema
o A pleural effusion that contains pus.
o Caused by conditions such as pneumonia, TB, lung abscess, infection of surgical
wounds.
o Complication of empyema is fibrothorax in which fibrous fusion of the visceral
and parietal pleurae occurs.
Signs/Symptoms: Common findings:
• Progressive dyspnea
• Decreased movement of the chest wall on affected side
• Pleuritic pain
• Dullness to percussion
• Absent or decreased breath sounds over affected area
• Chest X-ray indicates abnormality if effusion is >250 mL.
• Empyema symptoms…
o Fever
o Night sweats
o Cough
o Weight loss
Diagnosis: Thoracentesis obtains sample of fluid for analysis to determine type of effusion.
• Thoracentesis needle is inserted into the intercostal space and fluid is aspirated with a
syringe.
• 1000 to 1200 mL of pleural fluid is removed
• Complications include…
o Hypotension
o Hypoxemia
o Pulmonary edema
• Follow up with chest x-ray to rule out pneumothorax caused by thoracentesis.
• Monitor patient for respiratory distress during and after procedure.
Treatment: Main goal of treatment is to treat the underlying cause.
• Chemical pleurodesis may be used to sclerose the pleural space and prevent
reaccumulation of effusion fluid.
o Chest tubes are left in place after pleurodesis until fluid drainage is greater than
150 mL/day and no air leaks are noted
• Antibiotic therapy is needed in empyema to eradicate the causative organism.
o If a fibrothorax results from the empyema and causes severe pulmonary
restriction, a decortication surgical procedure is done to separate the
membranes.
Pleurisy
Definition & Cause: Pleurisy (pleuritis) in an inflammation of the pleura. Most common causes are pneumonia, TB,
chest trauma, pulmonary infarctions and neoplasms.
Two types…
• Fibrinous (dry) with fibrinous deposits on the pleural surface
• Serofibrinous (wet) with increased production of pleural fluid that may result in pleural
effusion
Signs/Symptoms: Pain of pleurisy is typically abrupt and sharp in onset and aggravated by inspiration.
• Breathing is shallow and rapid to avoid unnecessary movement of the pleura and chest
wall
• Friction rub is heard over areas where inflamed visceral/parietal pleurae rub against each
other
Treatment: Treatment is aimed at treating underlying cause
• Provide pain relief
o Analgesics
o Lie on or splint affected side
o Plint the rib cage when coughing
Atelectasis
Definition: Condition in which the alveoli are collapsed and airless. Commonly caused by airway obstruction
from retained exudates and secretions.
Treatment: Deep breathing prevents condition.
Chronic atelectasis may result in pulmonary fibrosis.
Sarcoidosis
A chronic, multisystem granulomatous disease of unknown cause that primarily affects the lungs. It
may also affect the skin, eyes, liver, kidney, heart and lymph nodes.
• Acute, subacute and self-limiting
• May be chronic with remissions and exacerbations
• Marked pulmonary fibrosis in restrictive lung disease
• Complication includes cor pulmonale
• No specific treatment…is self-limiting and patient recovers without treatment
• Corticosteroids may relieve symptoms and suppress acute inflammation
Pulmonary Edema
An abnormal accumulation of fluid in the alveoli and interstitial spaces of the lungs.
• Usually presents as a complication of heart and lung diseases
• Is a medical emergency and may be life-threatening
• Results from increased hydrostatic pressure or decreased oncotic pressure in pulmonary
capillaries
• Fluid first enters the interstitial space (interstitial edema), and continues into the alveoli
(alveolar edema) if leak is not resolved
• Most common cause is left-sided CHF
• May be asymptomatic until pulmonary fibrosis occurs
• Early signs may be paroxysmal nocturnal dyspnea as a result of increased hydrostatic
pressure in the lungs in the recumbent position
Pulmonary Embolism
A thromboembolism arising from venous circulation or right side of the heart (or from other sources
like amniotic fluid, air, fat, bone marrow or foreign intravenous material) that lodges in the
pulmonary vasculature.
• The result is a complete or partial occlusion of the pulmonary arterial blood flow to parts of
the lung.
• Lung tissue distal to the embolus is ventilated but not perfused.
May lead to pulmonary hypertension
Pulmonary Hypertension
Definition: Elevated pulmonary pressure resulting from an increase in pulmonary vascular resistance to blood
flow through small arteries and arterioles.
Cause: Primary Pulmonary Hypertension:
• Exact cause is unknown
• Characterized by mean pulmonary arterial pressure greater than 25 mmHg at rest or
greater than 30 mmHG with exercise
• Fen-Phen (diet drug) was linked to pulmonary hypertension
• Usually pulmonary circulation has low resistance and low pressure.
o A deficiency of vasodilator mediators from the epithelium may be a factor
Signs/Symptoms: Classic symptoms…
• Dyspnea on exertion and fatigue
• Exertional chest pain
• Dizziness
• Exertional syncope
• Cardiac output unable to increase in response to oxygen demands
• Right ventricular hypertrophy (cor pulmonale) occurs
• Leads to heart failure
Treatment: Relieve symptoms…
• Diuretics
• Calcium channel blockers
• Vasodilator therapy
• PROSTACYCLIN is standard of care. Promotes pulmonary vasodilation and reduces
pulmonary vascular resistance
o Must be administered by central line
o Very short half-life (6 mins)
o Complications result when medication is accidentally discontinued or when
infections develop at site of central line
Other: Secondary Pulmonary Hypertension
• Results from anatomic and vascular changes brought about by other disorders.
o Loss of capillaries as a result of alveolar wall damage (COPD);
o Stiffening of the pulmonary vasculature (pulmonary fibrosis); and
o Obstruction of blood flow (chronic emboli)
o Combination of conditions may occur, as in chronic bronchitis.
• Vasomotor/vasoconstriction may occur in alveolar hypoxia (blood is shunted to more
functional alveoli) which leads to pulmonary hypertension.
Cor Pulmonale
Enlargement of the right ventricle secondary to diseases of the lung, thorax or pulmonary
circulation. Pulmonary hypertension is usually a pre-existing condition of cor pulmonale.
• The most common cause is COPD
• Any disorder of the lungs can cause cor pulmonale
• Signs/symptoms are:
• Dyspnea
• Chronic productive cough
• Wheezing respirations
• Retrosternal or substernal pain
• Fatigue
• Polycythemia, increased total blood volume and viscosity of blood
• If heart failure is present…
o Peripheral edema
o Weight gain
o Distended neck veins
o Full, bounding pulse
o Enlarged liver
Treat underlying problem, plus…
• Long-term, low-flow oxygen
• Reduce vasoconstriction
• Diuretics
• Low sodium diet
• Bronchodilators
• Digitalis if left-sided heart failure
• Treat pulmonary hypertension: Vasodilator, calcium channel blockers and
anticoagulants
• Theophylline may reduce dyspnea
• Lung transplantation when all else fails.
OBSTRUCTIVE PULMONARY DISEASES Chapter 28
Asthma
Definition: An obstructive pulmonary disease characterized by airway inflammation, and non-specific hyperirritability
or hyper-responsiveness of the tracheobronchial tree (bronchospasm). The hyper-responsiveness seen
in asthma is caused by bronchoconstriction in response to physical, chemical and pharmacological
agents.
High morbidity is associated with asthma.
Asthma affects blacks more than whites in hospitalizations and deaths.
Cause: Allergens
• Exaggerated allergic response (IgE) to environmental factors (dust, pollen, grass, mites, roaches,
mold, dander, etc.).
Exercise
• “Exercise-Induced Asthma”
• Occurs within several minutes of vigorous exercise
• Bronchospasm, shortness of breath, cough, wheezing
• Prevent attacks with pre-medication, 2-3 minutes of stretching/warm-up and avoid exercise in
cold weather
Respiratory Infections
• Most common precipitating factor of an acute asthma attack.
o Avoid Beta blockers (propranolol, timolol, other “-olol” drugs) because they prevent
bronchodilation.
o Avoid ACE inhibitors; they cause coughs and trigger asthma symptoms.
• Food Allergies
o Avoid exposure to Tartrazine (yellow dye #5 found in many foods)
o Avoid vitamins
o Avoid sodium metabisulfite (food preservative in fruit, beer/wine and salad bars). They
interfere with prostaglandins and increase production of leukotrienes
(bronchoconstrictors).
o Symptoms occur in 15 minutes to 3 hours
o Causes profuse rhinorrhea, nausea, vomiting, intestinal cramps and diarrhea.
o Do NOT use corticosteroids or cromolyn. Use EPINEPHRINE after onset of symptoms.
o Avoidance diets may be needed to prevent asthma.
Gastroesophageal Reflux Disese (GERD)
• Theory is that reflux of stomach acid gets aspirated and causes reflex bronchoconstriction.
• GERD is primarily involved in nocturnal asthma.
• Patients with hiatal hernia, excessive stress and prior history of reflux or ulcer may have GERD
as an asthma trigger.
• Diagnose by monitoring esophageal pH simultaneously with peak expiratory flow rate (PEFR)
Emotional Stress
• Psychological or emotional stress may be a trigger
• Panic and anxiety during an attack may exacerbate and prolong the attack
Signs/Symptoms: Early-Phase Response
If untreated, inflammation leads to progressive, irreversible lung damage and structural changes in
the airway, known as airway remodeling.
Clinical Manifestations of asthma:
• Recurrent episodes of wheezing, breathlessness, dyspnea, chest tightness and cough (particularly
at night and in the early morning) after exposure to a trigger
• Characterized by prolonged expiration (wheezing upon expiration, air trapping and hyperinflation).
• Diminished or absent breath sounds during attack is an ominous sign and may indicate atelectasis
or pneumothorax.
• Person may sit upright or slightly bent forward using the accessory muscles of respiration to try to
get enough air.
• Attacks may last a few minutes to several hours.
• Symptoms of hypoxia occur: restlessness, anxiety, inappropriate behavior, increased pulse and
blood pressure, significantly increased respiratory rate (>30 breaths per minute) with use of
accessory muscles.
Classification: Mild Intermittent
• Symptoms < twice per week; nighttime < twice per month
• Asymptomatic with normal PEFR between attacks
• Exacerbations brief (hours to days)
• Intensity of exacerbations varies
• Treated with short-acting beta-agonist inhaler (may be combined with long-acting meds)
Mild Persistent
• Symptoms > twice per week but < once per day; nighttime > twice per month
• Exacerbations may affect activity
• Treated with anti-inflammatory inhaler
Moderate Persistent
• Daily symptoms; nighttime > once per week
• Daily use of inhaled short-acting beta agonist
• Exacerbations affect activity
• Exacerbations at least twice weekly and may last for days
• Treated with anti-inflammatory inhaler plus medium-dose corticosteroid inhaler.
Severe Persistent
• Continual symptoms; nighttime = frequent
• Limited physical activity
• Frequent exacerbations
• Treated with anti-inflammatory inhaler plus long-acting bronchodilator plus oral corticosteroid.
Status Asthmaticus
• Severe, life-threatening attack that does not respond to usual treatment.
• “The longer it lasts, the worse it gets and the worse it gets, the longer it lasts.”
• Caused by viruses; aspirin/NSAIDS; stress; environmental pollutants; allergens; abrupt
discontinuation of drug therapy (corticosteroids); abuse of aerosol medication; use of beta-
blockers.
• Symptoms same as asthma, but more severe and more prolonged with extreme anxiety, fear of
suffocation, diaphoresis and severely increased work of breathing.
• Chest remains in hyperinflated state; hypertension, sinus tachycardia and ventricular arrhythmias
may occur (related to hypoxemia).
Complications: Rib fractures, pneumothorax, pneumomediastinum, atelectasis, pneumonia and status asthmaticus.
Diagnosis: Asthma presents with same symptoms as other respiratory diseases. To diagnose asthma:
• History and physical examination
• Pulmonary function studies including response to bronchodilator therapy
• Peak expiratory flow monitoring
• Chest X-Ray
• Measurement of ABGs or Oximetry
• Allergy skin testing (if indicated)
• Blood level of eosinophils and IgE.
Treatment: Successful treatment depends on active partnership with patient.
• Mild Intermittent/Persistent Asthma: avoid triggers of attacks; pre-medicate before exercise
• Severe Persistent: inhaled or oral corticosteroids, inhaled or oral B2-agonists and theophylline.
o If patient requires continuous oral corticosteroids, use at lowest dose possible and
administer on alternate days to reduce systemic side effects.
• Acute Episode:
o Oxygen therapy immediately with pulse oximetry and ABGs
o Same interventions as for acute asthma (above), but may need to increase the
frequency and dose of inhaled bronchodilators to 2 to 6 puffs every 5 to 20 minutes
(depending upon medication).
o Continuous monitoring of patient is critical.
o B2-agonists (albuterol)
o Anticholinergics (Atrovent)
o methylxanthine derivatives (theophylline)
o Because inflammation is considered an early and persistent component of asthma, drug
therapy must be directed toward long-term suppression of the inflammation process.
o Anti-inflammatory Drugs
Corticosteroids
• Used in the long-term control of asthma
• Block the late-phase response, but not the immediate, early-phase, of
the attack.
• Onset is 3 to 6 hours after administration
• Inhaled corticosteroids:
o Must be used for 4 to 5 days before therapeutic effect
o Adverse effects: oropharyngeal candidiases, hoarseness
and dry cough (use a spacer and gargle with water after
each use to reduce side effects)
o Little risk of systemic effects (immune suppression)
• Oral corticosteroids
o Used for acute exacerbations
o Side effects include insomnia, heartburn, mood swings,
blurry vision, headache, increased appetite, weight gain.
o Maintenance doses should be used every other day to
minimize side effects.
o Post-menopausal women should increase calcium, vit D and
weight-bearing activities while on oral corticosteroids.
Mast Cell Stabilizers
• Cromolyn and Nedocromil
• Used in early-phase and prevent late-phase
• Reduces amount of O2 inhaled, thereby reducing the amount of O2 available to the body.
• Affects non-smokers when they are exposed to second-hand/side-stream smoke from cigarettes.
Infection
• Recurring respiratory tract infections impair normal defense mechanisms making alveoli more
susceptible to injury
o MDI or nebulizer
o Anticholinergics are more effective in emphysema
• Oxygen therapy
o Delivery
Nasal Cannula
Masks
• Simple (35 – 50% O2)
• Or by T-bar
Manual Breathing
• with bag
• with mouth in CPR (w/barrier)
o Humidification and nebulizers
o Complications of O2 Therapy
Absorption atelectasis
• Nitrogen from room air is usually retained in alveoli (not absorbed into
blood stream) to prevent atelectasis
• Fluid intake should be at least 3 L per day unless contraindicated, and between meals rather
than with meals
Role of Nurse: Interventions:
• Pneumonia, cor pulmonale, acute respiratory failure need medical intervention
• Pulmonary rehab (control and alleviate symptoms as possible; teach patient to achieve optimal
capability for ADLs; overall goal is improved quality of life)
• Activity considerations (Upper extremity work outs may improve function and reduce dyspnea;
teach to use O2 during ADLs; encourage walking with slow, pursed-lip breathing; allow 5-minute
recovery period from activity before using medication: keep a diary of exercises to record
progress)
• Teach client how to modify sexual activity to accommodate COPD (plan sexual activity during
time when beathing best; use slow pursed-lip breathing; refrain from sex after eating or other
strenuous activity; do not assume a dominant position; do not prolong foreplay)
• Teach client that adequate sleep is extremely important.
• Consider psychosocial aspects of patient’s life (coping; lifestyle changes; decreased energy for
socialization; depression; guilt)
Cystic Fibrosis
Definition: An autosomal recessive, multisystem disease characterized by altered function of the exocrine glands
involving the lungs, pancreas and sweat glands. Abnormally thick, abundant secretions from mucus
glands can lead to a chronic, diffuse, obstructive pulmonary disorder in almost all patients. Exocrine
pancreatic insufficiency is associated with most cases of CF; sweat glands excrete increased amounts of
sodium and chloride.
Cause: Mutations in a gene located on chromosome 7. (CFTR: Cystic Fibrosis Transmembrane Regulator).
Primary defect in CF is abnormally regulated chloride channel activity; manifestation is obstruction of the
ducts of exocrine glands with thick, viscous secretions that adhere to the lumen of the ducts; the glands
distal to the duct eventually undergo fibrosis.
Affects both upper and lower respiratory tracts.
Signs/Symptoms: Upper respiratory:
• Chronic sinusitis; nasal polyps
Lower respiratory:
• Progresses from small airway obstruction to larger airway obstruction and finally causes
destruction of lung tissue;
• Thick secretions obstruct bronchioles and lead to air trapping/hyperinflation of the lungs.
• Stasis of mucus provides excellent growth medium for bacteria = chronic airway infection
• Progressive loss of lung tissue results from inflammation and scarring and leads to chronic
hypoxia and pulmonary hypertension/cor pulmonale
• Hemoptysis (possibly fatal) and pneumothorax may be complications of CF
• CF is first obstructive (with mucus); later it becomes restrictive (fibrosis; lung destruction; thoracic
wall changes)
• Death from CF is a result of loss of pulmonary function.
• Pancreatic insufficiency leads to inability to absorb nutrients and diabetes mellitus
• GI problems; GERD and distal intestinal obstructive syndrome; constipation
Clinical manifestations
• In children: meconium ileus in newborn; failure to grow; clubbing; persistent cough with mucus
production; tachypnea; large, frequent bowel movements; large, protuberant abdomen with
emaciated limbs
• In adults: cough that becomes persistent and produces thick, purulent, often green sputum
• Recurring lung infections
• Weight loss
• Increased sputum
• Decreased pulmonary function
• Right, lower quadrant pain (abdomen)
• Loss of appetite, emesis, palpable abdominal mass
• Insufficient pancreatic enzyme release causes protein/fat malabsorption with frequent, bulky,
foul-smelling stools.
• Male sterility (but not impotent)
• Delayed menarche in females; diminished fertility (but can become pregnant)
Diagnosis: Sweat chloride test: >65 mEq/L suggest CF
Other tests:
• Chest x-ray
• Pulmonary function tests
• Fecal analysis for fat
• Duodenoscopy for quantitative determination of pancreatic enzymes
• DNA analysis can only confirm a diagnosis not be sole test (too many CF mutations)
Treatment: Goals:
• Promote clearance of secretions
• Control infection in the lungs
• Provide adequate nutrition
Airway clearance
• Draining of thick secretions
• DNase (Pulmozyme) decreases sputum viscosity and increases airflow
• Bronchodilators and mucolytics may be used
• CPT; postural drainage; positive expiratory pressure (PEP) breathing; aerobic exercise
Lung infections
• Antimicrobial treatment for infection
• Antibiotics specific to microorganism
• Home oxygen may be required for patients with cor pulmonale or hypoxemia
• Lung transplantation
• Surgical pleural abrasion or pleural stripping for recurrent pneumothorax
Pancreatic insufficiency
• Pancreatic enzyme replacement (lipase, protease, amylase) before each meal
• High calorie/high protein diet and multivitamins recommended
• Add salt when sweating is excessive (hot weather, fever, physical activity)
Gene Therapy (experimental)