Respiratory Diseases

UPPER RESPIRATORY TRACT INFECTION

Sinusitis (Acute/ Chronic)

URTI Cigarette Smoking Allergic rhinitis

Inflammatory Process

Edema of the mucous membrane

Hypersecretion of mucous

Infection

Assessment
Pain
Maxillary : Cheek, upper teeth Frontal : Above the eyebrows Ethmoid: in and around the eyes Sphenoid: behind the eye, occiput, top of the head

General Malaise Headache Fever Stuffy nose post nasal drip Cough

Management
Rest Increase fluid intake Hot wet packs Codeine, avoid ASA- increases the risk of developing nasal polyps Amoxicillin or other anti-infectives (acute- 710 days; chronic- up to 21 days)

 Nasal decongestants eg Sudafed, Dimetspp (used for 72 hours) Surgical Management

Functional Endoscopic Sinus Surgery (FESS) Caldwell- Luc Surgery (Radical Antrum Surgery)
Do not chew on affected side Caution with oral hygiene Do not wear dentures for 10 days Do not blow nose or sneeze for 2 weeks after removal of packing

 Ethmoidectomy Sphenoidotomy/ Ethmoidotomy Osteoplastic flap surgery for frontal sinusitis.

Tonsilitis/ Adenoiditis
Assessment:
Sore throat Frequent head colds Fever Snoring Dysphagia Mouth-breathing Earache Frequent Head Colds Bronchitis Foul Breath

Voice impairment Noisy Respiration Draining Ears

Management
Analgesic as ordered Antimicrobial as ordered Surgery: Tonsillectomy/ adenoidectomy (indicated if tonsillitis recurs 5-6 times a year) PRE-OP care
Assess for URTI- coughing and sneezing post-op may cause bleeding Check PT. Bleeding is a common post-op complication

Promote Rest Increase Fluid Intake Warm saline gargle

 POST-OP care
Prone, head turned to side, or lateral position When awake, semi-fowlers position Oral airway until swallowing reflex returns Monitor for hemorrhage
Frequent swallowing Bright red vomitus Increased PR

Promote Comfort
Ice collar, Acetaminophen; Avoid ASA

Foods and Fluids

Ice-cold fluids Bland foods

 Client Education
Avoid clearing of throat Avoid coughing, sneezing, blowing for 1-2 weeks 2-3 L of fluids/ day until ,outh odor disappears Avoid hard, scratchy foods until throat is healed Report s/sx of bleeding Throat discomfort between 4th to 8th postop day is expected Stool: Black/ dark for few days due to swallowed blood Plenty of rest for 2 weeks Avoid colds, overcrowded public places

Cancer of the Larynx

Predisposing Factors:
Cigarette Smoking Alcohol Abuse Voice Abuse Environmental pollutants Chronic Laryngitis (+) Family history

Assessment
Persistent hoarseness of voice Mass on anterior neck Dyspnea Dysphagia Chronic laryngitis Burning sensation with hot/acidic beverages Halitosis Hemoptysis Severe anorexia Severe anemia Severe weight loss

Management
Surgery: Subtotal/ total laryngectomy

Pre-op care:
Psychosocial support
Effects of total laryngectomy Loss of voice Permanent tracheostomy Loss of sesnse of smell Establish means of communication to be used postop Inability to :
Blow, sip soup and straw, whistle, gargle, do valsalva maneuver( unable to lift heavy objects; constipation)

 POST-OP care
Care of the Client with tracheostomy
Establish patient airway
Suction as necessary Use sterile technique Semi-fowlers position Use sterile NSS to lubricate suction catheter tip Apply suction during withdrawal of suction catheter Apply suction for 5-10 seconds (Max of 15 sec) Insert 3-5 of suction catheter Instill 2-5 ml of sterile NSS to liquify mucous secretions

 Prevent Infection
Cleanse stoma and tracheostomy at regular basis Change dressings and ties as necessary

Establish means of communication Provide psychosocial support Assist during speech therapy

 Client teaching:
Cover tracheostomy with poprous material Avoid swimming Avoid use of powder, spray aerosol near tracheostomy Regular follow-up care

LOWER RESPIRATORY TRACT INFECTION

Pneumonia
An infection of pulmonary tissue , including the interstitial spaces, the alveoli and the bronchioles The alveoli are filled with inflammatory products , creating consolidation The edema associated with inflammation stiffens the lungs , decreases lung compliance and vital capacity and causes hypoxemia

 Features include fever, chills, breathlessness and often dehydration Can be community acquired or hospital acquired Classified according to causative agent: bacterial, viral, fungal or parasitic CXR: presents as diffuse patches throughout the lungs or consolidation in a lobe

Classifications of Pneumonia
Bronchopneumonia
Patchy and scattered , often favoring the lower lobes Common in the immobile and the elderly Early signs include dullness to percussion and barely perceptible fine crackles which persist despite deep breathing.

Lobar Pneumonia
Localized pleuritic pain and bronchial breathing confined to a lobe

Pneumocystis Carinii Pneumonia

Due to HIV infection and medications given after an organ transplant Clinical features include dry cough, breathlesness, hypoxemia and features of stiff lungs

Nosocomial Pneumonia
Develops in patients confined in the hospital for more than 48 hours hospital acquired Leading cause of hospital-related mortality Caused by cross infections Klebsiella, Pseudomonas, E.coli, Enterobacteriacae, Proteus, Serratia

Legionella Pneumonia
Occurs in local outbreaks, especially in relation to cooling system, or after a trip abroad

Aspiration Pneumonia

Occurs in people who have inhaled unfriendly substances such as vomitus, or gastric acid Clinical signs include coughing, choking, added sounds in auscultation, gurgly voice or loss of voice, tachycardia and sometimes change in color

Chemical Pneumonia
Seen in ingestion of kerosene or inhalation of irritating gases

Radiation Pneumonitis
Mat follow radiation therapy for breast or lung cancer and usually occurs 6 weeks or more after completion or radiation therapy

Assessment
Chills Elevated temperature Pleuritic pain Rales, ronchi and wheezes Use of accessory muscles for breathing Cyanosis Mental status changes Sputum production

Diagnostics
CBC Creatinine Chest x-ray PA-L Sputum G/S and C/S Sputum AFB 3x (for TB suspect)

 Streptococcal p. (streptococcus pneumoniae)

History of previous infections Sudden onset, shaking and chills Cough, rusty or green (purulent sputum) Pleuritic chest pain, chest dull to percussion, crackles, bronchial breath sounds Treated with: Pen G, erythromycin, clinamycin, cephalosphorins, Cotrimoxazole Complications: shock, pleural effusion, superinfections, pericarditis, otitis media.

Manifestations of Commonly Encountered Pneumonia

Planning and Goals

The major goals of the patient may include improved airway patency, rest to conserve energy, proper fluid volume, adequate nutrition, an understanding of the treatment protocol and preventive measures, and absence of complications

Therapeutics
Antibiotic regimen for a max of 7-8 days only to minimize the emergence of resistance Switch therapy: Intravenous antibiotic treatment may be shifted to oral antibiotics after 48-72 hours if the following parameters are fulfilled:
A.) There is less cough and resolution of respiratory distress B.) the temperature is normalizing C.) the etiology is not a high risk (virulent or resistant) pathogen D.) there is no unstable co-morbid conditions or life threatening conditions E.) oral medications are tolerated

Implementation for Pneumonia

Administer oxygen as prescribed Monitor respiratory status Monitor for labored respirations, cyanosis ,cold clammy skin Encourage coughing and deep breathing and use of incentive spirometer Position in semi-fowlers to facilitate breathing and lung expansion

 Change position frequently and ambulate as tolerated to mobilize secretions Provide chest physiotherapy Perform nasotracheal suctioning if the client is unable to clear secretions Monitor pulse oximitry Monitor and record color, consistency, and amount of sputum Provide a high calorie, high protein diet with small frequent feedings

 Encourage fluids upto 3 liters per day to thin secretions unless contraindicated Provide a balance of rest and activity, increasing activity grasdually Administer antibiotics as prescribed Administer asntipyretics, bronchodilators, cough suppressants, mucolytic agents and expectorant as prescribed Prevent the spread of infection by hand washing and proper disposal of secretions.

 Also known as Chronic Obstructive Lung Disease (COLD) and Chronic Airflow Limitation (CAL) Characterized by airflow limitation that is not fully reversible There is progressive airflow limitation into and out of the lungs, elevated airway resistance, irreversible lung distention and ABG imbalance

 Caused by Emphysema and Chronic Bronchitis or a combination of both. Leads to pulmonary insufficiency, pulmonary hypertension and cor pulmonale

Risk factors of COPD:

Exposure to tobacco smoke (80-90 % of COPD cases) Passive smoking Occupational exposure Ambient air pollution Genetic abnormalities, including a deficiency of alpha 1- antitrypsin.

COPD - chronic bronchitis

A disease of the airways, defined as the presence of irritating cough (smokers cough) and sputum production for at least 3 months is each of 2 consecutive years Develops in heavy smokers In many cases , smoke or other environmental pollutants irritate the airways resulting in hypersecretion of mucous and inflammation

 Clients abandons the fight for normal blood gases and feels less breathless, but pays for symptomatic relief with edema, cyanosis and inadequate gas exchange (Blue bloaters)

COPD - emphysema

An abnormal distention of the air spaces beyond the terminal bronchioles with destruction of the walls of the alveoli Commonly caused by smoking Protein breakdown is the villain which causes erosion of the alveolar system, dilation of distal air spaces and destruction of elastic fibers

 Alveoli lose their elastic recoil, then weaken and rupture. Air remains trapped in the lungs, (formation of air pockets or bullae); carbon dioxide accumulates (hypercapnia) with resulting respiratory acidosis Cor pulmonale is one of the complications of emphysema

 Client with emphysema tries to maintain near normal blood gases at the expense of brathlesness and weight loss, no cyanosis occurs (pink puffers) The flat diaphragm works paradoxically and becomes expiratory in action, thus, drawing the lower ribs in inspiration ( Hoovers sign)

Clinical syndrome of COPD

Patients with empysematous, dyspneic or Type A COPD are referred as PINK PUFFERS Those with bronchitic, tussive or Type B COPD are referred as BLUE BLOATERS

Pink puffers
Have predominant emphysema Symptoms of relatively advanced age ( >60 yrs) Progressive exertional dyspnea, weight loss, little or no cough and expectoration. Mild hypoxia, hypocapnia and little improvement in airflow after treatment with bronchodilators. They usually undergo a slowly progressive downhill course

Blue Bloaters
Predominant chronic bronchitis At relatively young age Chronic cough and expectoration, episodic dyspnea and weight gain Wheezing and ronchi, cor pulmonale, accompanied by edema and cyanosis Severe hypoxia, hypercapnia, polycythemia Improvede airflow after treatment with bronchodilators and relatively preserved lung volumes.

Nursing implementation for COPD

Monitor vital signs Administer a low concentration of oxygen (2-3 L/min) as prescribed ; in emphysema, the stimulus to breathe is a low PO2 instead of an increased in PCO2 Monitor pulse oximetry Provide respiratory treatments and chest physiotherapy

 Instruct the client in diaphragmatic or abdominal and pursed-lip breathing techniques Record the color, amount and consistency of sputum Suction the client, if necessary , to clear airway and prevent infection Monitor weight Encourage small frequent meals to prevent dyspnea

 Provide high CHO and high Protein diet with supplements Encourage fluids up to 3000 ml/day to keep secretions thin unless contraindicated Position in high fowlers or orthopneic position Allow activity as tolerated Administer bronchodilators as prescribed and instruct the client in the use of both oral and inhalant medications

 Administer corticosteroids as prescribed to reduce inflammation Administer mucolytics as prescribed to thin secretions Administer antibiotics for infection as prescribed

 Coping measures:
Patients experience anxiety, apprehension, frustration of having to work to breathe Adapt a hopeful and encouraging attitude Emphasis should be in controlling his symptoms and increasing self esteem and sense of mastery and well-being

 Patient education and home health care:

Stop smoking Tell him what to expect. He and family caring for him will need patience Help patient accept set realistic short term and long term goals The objective is to increase exercise tolerance and prevent further loss of pulmonary function Educate the patient about the disease process

 Recognize the signs and symptoms of respiratory infection and hypoxia Adhere to activity limitations, altering rest periods with activity Avoid exposure to individuals with infections and avoid crowds Instruct to avoid extremes of heat and cold Demonstrate pursed-lip and diaphragmatic or abdominal breathing

 Instruct the client in the use of medications and inhalers Instruct the client in the use of oxygen therapy Instruct the client in nutritional requirements Avoid eating gas-producing foods, spicy foods, and extremely hot and cold foods Instruct in the importance of receiving immunizations as recommended

When dusting , use a wet cloth Avoid powerful odors Avoid extremes in temperature Avoid fireplaces, pets, and feather pillows

Asthma

 An intermittent reversible airway obstruction characterized by hyperresponsiveness or hyperirritability and inflammation of the airways Substances that have no effect when inhaled by normal individuals can cause bronchoconstrictions in patients with asthma

 A principal feature of asthma is its extreme variability, both from patient to patient and from time to time in the same patient. Allergy is the strongest predisposing factor for asthma

Incidence and etiology:

Asthma occurs in 3-8 % of the population It is traditionally divided into 3 forms
An allergic form extrinsic form An intrinsic form Mixed asthma

Extrinsic (allergic) Age of Onset Symptoms

3- 35 y.o Season of perennial, frequently pollen and mold related Clear and foamy positive Positive and correlating High or normal Good response to immunotherapy and bronchodilator

Intrinsic (infectious / miscellaneous)

Under 3, over 35-40 Worse in winter, cold seasons, exacerbated by cold air, air pollution, and primarily by infection Thick and white or discolored No greater than in general population Negative or positive noncorrelating normal Poor response to bronchodilators, no response to immunotherapy

Mucus Family History Skin Tests Serum Ig E Response to therapy

 The following may trigger an asthma attack:

Allergenic foods (eggs, nuts, wheat, dairy products) Chest infection Drugs e.g. NSAIDS, ASA Exercise Car exhaust Exercise Frustrated expression of emotion Premenstruation Pollen

Smoking Warm blooded pets Weather Education about these risk factors and prevention is vital in care of patients in asthma

Other classification of asthma and their clinical features

Mild chronic asthma
-manifests an intermittent dry cough often at night or morning and wheezes once or twice a week

Severe Chronic Asthma

-frequent exacerbations and symptoms that significantly affect quality of life

 Unstable- most severe form; also known as

brittle asthma which shows greatly fluctuating peak flows, persistent symptoms despite multiple drug treatment and unpredictable severe falls in lung functioning, often without known precipitating factors.

Acute asthma- large airways are obstructed

by bronchospasm and the small airways by edema and mucus plugging.

 Associated with breathlessness, rapid breathing and abdominal paradox

Severe acute asthma

Most commonly develops slowly, often after several weeks of wheezing Alternately, attack is sudden, especially if there has been poor drug control Can be fatal within minutes

Diagnosis:
Sputum analysis
-may appear purulent -reveal Curschmanns spirals - reveals Charcots Layden crystals

Hematologic studies- modest leukocytosis and eosinophilia Pulmonary function testing Chest x-ray

Nursing Assessment:

Cough Dyspnea Wheezing Diaphoresis Tachycardia General chest tightness Hypoxemia Central cyanosis History- + family hx- periodic reversible airflow obstruction

Nursing Implementation:
Assess airway patency Elevate head Administer humidified O2 Continuously monitor resp status:
Give Medications as prescribed (Bronchodilators)
Sympathomimetics ( B2 agonists) Methlyxanthines (Theophylline) Anti cholinergic agents (Ipratropium)

 DO NOT GIVE BETA BLOCKERS!!!!! Anti-inflammatory agents:

Corticosteroids and cromolyn sodium Prevent exacerbations Teaching:
Positioning Pursed-lip exercises Nutrition: Avoid over feeding!