Alterations in Alterations in Respiratory FunctionRespiratory Function

John Bert N. Macato RN,EMT, RMJohn Bert N. Macato RN,EMT, RM

Sinusitis (Acute/ Chronic)Sinusitis (Acute/ Chronic)

URTICigarette Smoking

Allergic rhinitis

Inflammatory Process

Edema of the mucous membrane

Hypersecretion of mucous

Infection

AssessmentAssessment PainPain

Maxillary : Cheek, upper teethMaxillary : Cheek, upper teeth Frontal : Above the eyebrowsFrontal : Above the eyebrows Ethmoid: in and around the eyesEthmoid: in and around the eyes Sphenoid: behind the eye, occiput, top of Sphenoid: behind the eye, occiput, top of

the headthe head

General MalaiseGeneral Malaise HeadacheHeadache FeverFever Stuffy noseStuffy nose post nasal drippost nasal drip CoughCough

Nursing InterventionsNursing Interventions RestRest Increase fluid intakeIncrease fluid intake Hot wet packsHot wet packs Codeine, avoid ASA- increases Codeine, avoid ASA- increases

the risk of developing nasal the risk of developing nasal polypspolyps

Amoxicillin or other anti-Amoxicillin or other anti-infectives (acute- 7-10 days; infectives (acute- 7-10 days; chronic- upto 21 days)chronic- upto 21 days)

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

Surgical ManagementSurgical Management Functional Endoscopic Sinus Functional Endoscopic Sinus

Surgery (FESS)Surgery (FESS) Caldwell- Luc Surgery (Radical Caldwell- Luc Surgery (Radical

Antrum Surgery)Antrum Surgery) Do not chew on affected sideDo not chew on affected side Caution with oral hygieneCaution with oral hygiene Do not wear dentures for 10 daysDo not wear dentures for 10 days Do not blow nose or sneeze for 2 Do not blow nose or sneeze for 2

weeks after removal of packingweeks after removal of packing

EthmoidectomyEthmoidectomy Sphenoidotomy/ EthmoidotomySphenoidotomy/ Ethmoidotomy Osteoplastic flap surgery for Osteoplastic flap surgery for

frontal sinusitis.frontal sinusitis.

Tonsilitis/ AdenoiditisTonsilitis/ Adenoiditis Assessment:Assessment:

Sore throatSore throat Frequent head coldsFrequent head colds FeverFever SnoringSnoring DysphagiaDysphagia Mouth-breathingMouth-breathing EaracheEarache Frequent Head ColdsFrequent Head Colds BronchitisBronchitis Foul BreathFoul Breath Voice impairmentVoice impairment Noisy RespirationNoisy Respiration Draining EarsDraining Ears

Nursing InterventionsNursing Interventions

Promote RestPromote Rest Increase Fluid IntakeIncrease Fluid Intake Warm saline gargleWarm saline gargle Analgesic as orderedAnalgesic as ordered Antimicrobial as orderedAntimicrobial as ordered

Surgery: Tonsillectomy/ Surgery: Tonsillectomy/ adenoidectomy (indicated if adenoidectomy (indicated if tonsillitis recurs 5-6 times a tonsillitis recurs 5-6 times a year)year)

PRE-OP carePRE-OP care Assess for URTI- coughing and Assess for URTI- coughing and

sneezing post-op may cause sneezing post-op may cause bleedingbleeding

Check PT. Bleeding is a common Check PT. Bleeding is a common post-op complicationpost-op complication

POST-OP carePOST-OP care Prone, head turned to side, or lateral Prone, head turned to side, or lateral

positionposition When awake, semi-fowler’s positionWhen awake, semi-fowler’s position Oral airway until swallowing reflex Oral airway until swallowing reflex

returnsreturns Monitor for hemorrhageMonitor for hemorrhage

Frequent swallowingFrequent swallowing Bright red vomitusBright red vomitus Increased PRIncreased PR

Promote ComfortPromote Comfort Ice collar, Acetaminophen; Avoid ASAIce collar, Acetaminophen; Avoid ASA

Foods and FluidsFoods and Fluids Ice-cold fluidsIce-cold fluids Bland foodsBland foods

Client EducationClient Education Avoid clearing of throatAvoid clearing of throat Avoid coughing, sneezing, blowing for 1-Avoid coughing, sneezing, blowing for 1-

2 weeks2 weeks 2-3 L of fluids/ day until ,outh odor 2-3 L of fluids/ day until ,outh odor

disappearsdisappears Avoid hard, scratchy foods until throat is Avoid hard, scratchy foods until throat is

healedhealed Report s/sx of bleedingReport s/sx of bleeding Throat discomfort between 4Throat discomfort between 4thth to 8 to 8thth

postop day is expectedpostop day is expected Stool: Black/ dark for few days due to Stool: Black/ dark for few days due to

swallowed bloodswallowed blood Plenty of rest for 2 weeksPlenty of rest for 2 weeks Avoid colds, overcrowded public places Avoid colds, overcrowded public places

Ca of the LarynxCa of the Larynx

Predisposing Factors:Predisposing Factors: Cigarette SmokingCigarette Smoking Alcohol AbuseAlcohol Abuse Voice AbuseVoice Abuse Environmental pollutantsEnvironmental pollutants Chronic LaryngitisChronic Laryngitis (+) Family history(+) Family history

AssessmentAssessment Persistent hoarseness of voicePersistent hoarseness of voice Mass on anterior neckMass on anterior neck DyspneaDyspnea DysphagiaDysphagia Chronic laryngitisChronic laryngitis Burning sensation with hot/acidic Burning sensation with hot/acidic

beveragesbeverages HalitosisHalitosis HemoptysisHemoptysis Severe anorexiaSevere anorexia Severe anemiaSevere anemia Severe weight lossSevere weight loss

ManagementManagement Surgery: Subtotal/ total Surgery: Subtotal/ total

laryngectomylaryngectomy Pre-op care:Pre-op care:

Psychosocial supportPsychosocial support Effects of total laryngectomyEffects of total laryngectomy Loss of voiceLoss of voice Permanent tracheostomyPermanent tracheostomy Loss of sesnse of smellLoss of sesnse of smell Establish means of communication to Establish means of communication to

be used post-opbe used post-op Inability to :Inability to :

Blow, sip soup and straw, whistle, Blow, sip soup and straw, whistle, gargle, do valsalva maneuver( unable to gargle, do valsalva maneuver( unable to lift heavy objects; constipation)lift heavy objects; constipation)

POST-OP carePOST-OP care Care of the Client with Care of the Client with

tracheostomytracheostomy Establish patient airwayEstablish patient airway

Suction as necessarySuction as necessary Use sterile techniqueUse sterile technique Semi-fowler’s positionSemi-fowler’s position Use sterile NSS to lubricate suction Use sterile NSS to lubricate suction

catheter tipcatheter tip Apply suction during withdrawal of Apply suction during withdrawal of

suction cathetersuction catheter Apply suction for 5-10 seconds (Max of Apply suction for 5-10 seconds (Max of

15 sec)15 sec) Insert 3-5 “ of suction catheterInsert 3-5 “ of suction catheter Instill 2-5 ml of sterile NSS to liquify Instill 2-5 ml of sterile NSS to liquify

mucous secretionsmucous secretions

Prevent InfectionPrevent Infection Cleanse stoma and tracheostomy Cleanse stoma and tracheostomy

at regular basisat regular basis Change dressings and ties as Change dressings and ties as

necessarynecessary Establish means of Establish means of

communicationcommunication Provide psychosocial supportProvide psychosocial support Assist during speech therapyAssist during speech therapy

Client teaching:Client teaching: Cover tracheostomy with poprous Cover tracheostomy with poprous

materialmaterial Avoid swimmingAvoid swimming Avoid use of powder, spray Avoid use of powder, spray

aerosol near tracheostomyaerosol near tracheostomy Regular follow-up careRegular follow-up care

PneumoniaPneumonia

An infection of pulmonary tissue , An infection of pulmonary tissue , including the interstitial spaces, the including the interstitial spaces, the alveoli and the bronchiolesalveoli and the bronchioles

The alveoli are filled with The alveoli are filled with inflammatory products , creating inflammatory products , creating consolidationconsolidation

The edema associated with The edema associated with inflammation stiffens the lungs , inflammation stiffens the lungs , decreases lung compliance and vital decreases lung compliance and vital capacity and causes hypoxemiacapacity and causes hypoxemia

Features include fever, chills, Features include fever, chills, breathlessness and often breathlessness and often dehydrationdehydration

Can be community acquired or Can be community acquired or hospital acquiredhospital acquired

Classified according to Classified according to causative agent: bacterial, viral, causative agent: bacterial, viral, fungal or parasiticfungal or parasitic

CXR: presents as diffuse CXR: presents as diffuse patches throughout the lungs or patches throughout the lungs or consolidation in a lobeconsolidation in a lobe

A sputum culture identifies the A sputum culture identifies the organismorganism

WBC and ESR are elevatedWBC and ESR are elevated

Classifications of PneumoniaClassifications of Pneumonia

BronchopneumoniaBronchopneumonia Patchy and scattered , often Patchy and scattered , often

favoring the lower lobesfavoring the lower lobes Common in the immobile and the Common in the immobile and the

elderlyelderly Early signs include dullness to Early signs include dullness to

percussion and barely perceptible percussion and barely perceptible fine crackles which persist despite fine crackles which persist despite deep breathing.deep breathing.

Lobar PneumoniaLobar Pneumonia

Localized pleuritic pain and Localized pleuritic pain and bronchial breathing confined to bronchial breathing confined to a lobea lobe

Pneumocystis Carinii Pneumocystis Carinii PneumoniaPneumonia

Due to HIV infection and Due to HIV infection and medications given after an medications given after an organ transplantorgan transplant

Clinical features include dry Clinical features include dry cough, breathlesness, cough, breathlesness, hypoxemia and features of stiff hypoxemia and features of stiff lungs lungs

Nosocomial PneumoniaNosocomial Pneumonia

Develops in patients confined in Develops in patients confined in the hospital for more than 48 the hospital for more than 48 hours – hospital acquiredhours – hospital acquired

Leading cause of hospital-Leading cause of hospital-related mortalityrelated mortality

Caused by cross infectionsCaused by cross infections Klebsiella, Pseudomonas, Klebsiella, Pseudomonas,

E.coli, Enterobacteriacae, E.coli, Enterobacteriacae, Proteus, SerratiaProteus, Serratia

Legionella PneumoniaLegionella Pneumonia

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

Aspiration PneumoniaAspiration Pneumonia

Occurs in people who have Occurs in people who have inhaled unfriendly substances inhaled unfriendly substances such as vomitus, or gastric acidsuch as vomitus, or gastric acid

Clinical signs include coughing, Clinical signs include coughing, choking, added sounds in choking, added sounds in auscultation, gurgly voice or loss auscultation, gurgly voice or loss of voice, tachycardia and of voice, tachycardia and sometimes change in colorsometimes change in color

Chemical PneumoniaChemical Pneumonia

Seen in ingestion of kerosene or Seen in ingestion of kerosene or inhalation of irritating gasesinhalation of irritating gases

Radiation PneumonitisRadiation Pneumonitis

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

AssessmentAssessment

ChillsChills Elevated temperatureElevated temperature Pleuritic painPleuritic pain Rales, ronchi and wheezesRales, ronchi and wheezes Use of accessory muscles for Use of accessory muscles for

breathingbreathing CyanosisCyanosis Mental status changesMental status changes Sputum productionSputum production

DiagnosticsDiagnostics

CBCCBC CreatinineCreatinine Chest x-rayChest x-ray PA-LPA-L Sputum G/S and C/SSputum G/S and C/S Sputum AFB 3x (for TB suspect)Sputum AFB 3x (for TB suspect)

Manifestations of Commonly Manifestations of Commonly Encountered PneumoniaEncountered Pneumonia Streptococcal p. (streptococcus Streptococcal p. (streptococcus

pneumoniae)pneumoniae) History of previous infectionsHistory of previous infections Sudden onset, shaking and chillsSudden onset, shaking and chills Cough, rusty or green (purulent Cough, rusty or green (purulent

sputum)sputum) Pleuritic chest pain, chest dull to Pleuritic chest pain, chest dull to

percussion, crackles, bronchial breath percussion, crackles, bronchial breath soundssounds

Treated with: Pen G, erythromycin, Treated with: Pen G, erythromycin, clinamycin, cephalosphorins, clinamycin, cephalosphorins, CotrimoxazoleCotrimoxazole

Complications: shock, pleural effusion, Complications: shock, pleural effusion, superinfections, pericarditis, otitis superinfections, pericarditis, otitis media.media.

Staphylococcal PneumoniaStaphylococcal Pneumonia(Staphylococcus aureus)(Staphylococcus aureus) Prior history of viral infectionPrior history of viral infection Insidious onset of cough, yellow, Insidious onset of cough, yellow,

bloode-streaked mucousbloode-streaked mucous Fever, pleuritic chest pain, varied Fever, pleuritic chest pain, varied

pulse rate, may be slow in proportion pulse rate, may be slow in proportion to temperatureto temperature

Treated with: Nafcillin, methicillin, Treated with: Nafcillin, methicillin, clindamycin, vancomycin, cephalotinclindamycin, vancomycin, cephalotin

Complications: effusion/ Complications: effusion/ pneumothorax, lung abscess, pneumothorax, lung abscess, empyema, meningitis empyema, meningitis

Klebsiella pneumonia Klebsiella pneumonia (Klebsiella pneumoniae)(Klebsiella pneumoniae) Sudden high fever, chills, Sudden high fever, chills,

pleuritic pain, hemoptysispleuritic pain, hemoptysis Dyspnea, cyanosisDyspnea, cyanosis Dark brown, gelatinous sputumDark brown, gelatinous sputum Treated with: gentamicin, Treated with: gentamicin,

cefazolin, tobramycincefazolin, tobramycin Complications: lung abscesses Complications: lung abscesses

with cyst formation, empyema, with cyst formation, empyema, pericarditispericarditis

Mycoplasma pneumonia Mycoplasma pneumonia (Mycoplasma pneumoniae)(Mycoplasma pneumoniae)

Gradual onset, severe Gradual onset, severe headacheheadache

Irritating hacking cough, scanty Irritating hacking cough, scanty mucoid sputummucoid sputum

Anorexia, malaise, fever, Anorexia, malaise, fever, congestion, sore throatcongestion, sore throat

Treated with : erythromycin, Treated with : erythromycin, tetracyclinetetracycline

Viral pneumoniaViral pneumonia

Influenza, parainfluenza, RSV, Influenza, parainfluenza, RSV, adenovirus, varicella, rubella, adenovirus, varicella, rubella, rubeola, HSV, cytomegalovirus, rubeola, HSV, cytomegalovirus, Epstein Barr virusEpstein Barr virus

CoughCough Pronounced constitutional Pronounced constitutional

symptoms (severe headache, symptoms (severe headache, anorexia, fever and myalgia)anorexia, fever and myalgia)

Nursing DiagnosesNursing Diagnoses

Ineffective airway clearance related Ineffective airway clearance related to copious tracheobronchial to copious tracheobronchial secretionssecretions

Risk for deficient fluid volume related Risk for deficient fluid volume related to fever and dyspneato fever and dyspnea

Activity intolerance related to Activity intolerance related to impaired respiratory functionimpaired respiratory function

Imbalanced nutrition less than body Imbalanced nutrition less than body requirementsrequirements

Deficient knowledge and about Deficient knowledge and about treatment regimen and preventive treatment regimen and preventive health measures. health measures.

Planning and GoalsPlanning and Goals

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

TherapeuticsTherapeutics Antibiotic regimen for a max of 7-8 Antibiotic regimen for a max of 7-8

days only to minimize the days only to minimize the emergence of resistanceemergence of resistance

Switch therapy: Intravenous Switch therapy: Intravenous antibiotic treatment may be shifted to antibiotic treatment may be shifted to oral anti8biotics after 48-72 hours if oral anti8biotics after 48-72 hours if the following parameters are fulfilled:the following parameters are fulfilled: A.) ther is less cough and resolution of A.) ther is less cough and resolution of

respiratory distressrespiratory distress B.) the temperature is normalizingB.) the temperature is normalizing C.) the etiology is not a high risk C.) the etiology is not a high risk

(virulent or resistant) pathogen(virulent or resistant) pathogen D.) there is no unstable co-morbid D.) there is no unstable co-morbid

conditions or life threatening conditionsconditions or life threatening conditions E.) oral medications are tolerated E.) oral medications are tolerated

For abundant secretions, may For abundant secretions, may give acetylcysteine (Fluimucil) give acetylcysteine (Fluimucil) 100mg or 200mg sachet 100mg or 200mg sachet dissolved in ½ glass water TID. dissolved in ½ glass water TID. Discontinue if patient has Discontinue if patient has wheezing. wheezing.

Nursing Implementation for Nursing Implementation for PneumoniaPneumonia Administer oxygen as prescribedAdminister oxygen as prescribed Monitor respiratory statusMonitor respiratory status Monitor for labored respirations, Monitor for labored respirations,

cyanosis ,cold clammy skincyanosis ,cold clammy skin Encourage coughing and deep Encourage coughing and deep

breathing and use of incentive breathing and use of incentive spirometerspirometer

Position in semi-fowler’s to facilitate Position in semi-fowler’s to facilitate breathing and lung expansionbreathing and lung expansion

Change position frequently and Change position frequently and ambulate as tolerated to mobilize ambulate as tolerated to mobilize secretionssecretions

Provide chest physiotherapyProvide chest physiotherapy Perform nasotracheal suctioning if Perform nasotracheal suctioning if

the client is unable to clear the client is unable to clear secretionssecretions

Monitor pulse oximitryMonitor pulse oximitry Monitor and record color, Monitor and record color,

consistency, and amount of sputumconsistency, and amount of sputum Provide a high calorie, high protein Provide a high calorie, high protein

diet with small frequent feedingsdiet with small frequent feedings

Encourage fluids upto 3 liters per Encourage fluids upto 3 liters per day to thin secretions unless day to thin secretions unless contraindicatedcontraindicated

Provide a balance of rest and Provide a balance of rest and activity, increasing activity grasduallyactivity, increasing activity grasdually

Administer antibiotics as prescribedAdminister antibiotics as prescribed Administer asntipyretics, Administer asntipyretics,

bronchodilators, cough bronchodilators, cough suppressants, mucolytic agents and suppressants, mucolytic agents and expectorant as prescribedexpectorant as prescribed

Prevent the spread of infection by Prevent the spread of infection by hand washing and proper disposal of hand washing and proper disposal of secretions.secretions.

Client Education for Client Education for PneumoniaPneumonia The importance of rest, proper The importance of rest, proper

nutrition and adequate fluid intakenutrition and adequate fluid intake Avoid chilling and exposure to Avoid chilling and exposure to

individual with respiratory infections individual with respiratory infections or virusesor viruses

Instruct client regarding medications Instruct client regarding medications and the use of inhalants as and the use of inhalants as prescribedprescribed

Instruct the client to notify physician Instruct the client to notify physician if chills, fever, dyspnea, hemoptysis if chills, fever, dyspnea, hemoptysis or increased fatigue occursor increased fatigue occurs

Instruct the client in the importance Instruct the client in the importance of receiving immunizations as of receiving immunizations as recommendedrecommended

Prevention and risk factors for Prevention and risk factors for PneumoniaPneumonia Any condition producing mucus or Any condition producing mucus or

bronchial obstruction and interfering bronchial obstruction and interfering with normal drainage (COPD, CA)with normal drainage (COPD, CA)

Immunosuppressed patientsImmunosuppressed patients People who smoke, because People who smoke, because

cigarette smoke disrupts mucociliary cigarette smoke disrupts mucociliary and macrophage activityand macrophage activity

Immobile patients breathing Immobile patients breathing shallowlyshallowly

Patients with depressed cough reflex Patients with depressed cough reflex owing to drugs or weakness, has owing to drugs or weakness, has aspirated foreign material during aspirated foreign material during unconsciousness or those with unconsciousness or those with abnormal swallowing mechanismabnormal swallowing mechanism

NPO patients receiving antibiotics, NPO patients receiving antibiotics, has increased pharyngeal has increased pharyngeal colonization of bacteriacolonization of bacteria

Frequently intoxicated people. Frequently intoxicated people. Alcohol suppresses body reflexes, Alcohol suppresses body reflexes, WBC mobilization, trachiobronchial WBC mobilization, trachiobronchial ciliary mobilizationciliary mobilization

Patients receiving sedativesPatients receiving sedatives prevention through frequent prevention through frequent

suctioning of unconscious patients, suctioning of unconscious patients, with poor gag and cough reflexeswith poor gag and cough reflexes

Elderly people are at riskElderly people are at risk Patients receiving respiratory Patients receiving respiratory

therapy using not properly cleaned therapy using not properly cleaned equipment.equipment.

Lung abscessLung abscess

A localized lesion in the lung A localized lesion in the lung containing pus and necrotic tissue containing pus and necrotic tissue that collapses and forms cavities, or that collapses and forms cavities, or pockets in the lungspockets in the lungs

May occur from aspiration of vomitus May occur from aspiration of vomitus or infected material from the upper or infected material from the upper respiratory tract; or secondary to respiratory tract; or secondary to bronchial obstruction due to a tumor.bronchial obstruction due to a tumor.

May also be a sequela of necrotizing May also be a sequela of necrotizing pneumonia ,tuberculosis. Pulmonary pneumonia ,tuberculosis. Pulmonary embolism, trauma, bronchial embolism, trauma, bronchial neoplasms.neoplasms.

Nursing AssessmentNursing Assessment

Initially cough, with small amount Initially cough, with small amount of sputum, a low-grade fever and of sputum, a low-grade fever and malaisemalaise

In time, sputum becomes copious In time, sputum becomes copious and often foul- smelling, and often foul- smelling, sometimes containing bloodsometimes containing blood

Pleuritic chest painPleuritic chest pain Onset is sudden, with chills, high Onset is sudden, with chills, high

fever cough and malaisefever cough and malaise

Measures to reduce risk of Measures to reduce risk of suppurative lung diseasesuppurative lung disease

Antibiotic therapy before dental Antibiotic therapy before dental manipulation.manipulation.

Adequate dental and oral Adequate dental and oral hygiene since anaerobic hygiene since anaerobic bacteria play a role in the bacteria play a role in the pathogenesis of lung abscesspathogenesis of lung abscess

Give appropriate antimicrobial Give appropriate antimicrobial therapy to those with pneumoniatherapy to those with pneumonia

ManagementManagement

Postural drainage, effective Postural drainage, effective coughing and deep breathing coughing and deep breathing exercisesexercises

Bronchoscopy may be needed to Bronchoscopy may be needed to drain abscessdrain abscess

High CHON, high CHO dietHigh CHON, high CHO diet Surgery if medical intervention is Surgery if medical intervention is

inadequateinadequate Emotional supportEmotional support

Surgical intervention is rare:Surgical intervention is rare: Pulmonary resection (lobectomy) Pulmonary resection (lobectomy)

when there is massive hemoptysis when there is massive hemoptysis or no response to medical or no response to medical management.management.

Pharmacologic TherapyPharmacologic Therapy IV: Clindamycin (Cloecin)IV: Clindamycin (Cloecin)

meropenem (Merrem)meropenem (Merrem) piperacillin/tazobaqctam (Zosyn)piperacillin/tazobaqctam (Zosyn) May last for 4-8 weeks.May last for 4-8 weeks.

COPDCOPD

Also known as Chronic Obstructive Also known as Chronic Obstructive Lung Disease (COLD) and Chronic Lung Disease (COLD) and Chronic Airflow Limitation (CAL)Airflow Limitation (CAL)

Characterized by airflow limitation Characterized by airflow limitation that is not fully reversiblethat is not fully reversible

There is progressive airflow limitation There is progressive airflow limitation into and out of the lungs, elevated into and out of the lungs, elevated airway resistance, irreversible lung airway resistance, irreversible lung distention and ABG imbalancedistention and ABG imbalance

Caused by Emphysema and Caused by Emphysema and Chronic Bronchitis or a Chronic Bronchitis or a combination of both.combination of both.

Leads to pulmonary Leads to pulmonary insufficiency, pulmonary insufficiency, pulmonary hypertension and cor pulmonalehypertension and cor pulmonale

Risk factors of COPD:Risk factors of COPD:

Exposure to tobacco smoke (80-Exposure to tobacco smoke (80-90 % of COPD cases)90 % of COPD cases)

Passive smokingPassive smoking Occupational exposureOccupational exposure Ambient air pollutionAmbient air pollution Genetic abnormalities, including Genetic abnormalities, including

a deficiency of alpha 1- a deficiency of alpha 1- antitrypsin.antitrypsin.

COPD- chronic bronchitisCOPD- chronic bronchitis A disease of the airways, defined as A disease of the airways, defined as

the presence of irritating cough the presence of irritating cough (smoker’s cough) and sputum (smoker’s cough) and sputum production for at least 3 months is production for at least 3 months is each of 2 consecutive yearseach of 2 consecutive years

Develops in heavy smokersDevelops in heavy smokers In many cases , smoke or other In many cases , smoke or other

environmental pollutants irritate the environmental pollutants irritate the airways resulting in hypersecretion of airways resulting in hypersecretion of mucous and inflammationmucous and inflammation

This constant irritation causes the This constant irritation causes the mucus-secreting glands and goblet mucus-secreting glands and goblet cells to increase in number, ciliary cells to increase in number, ciliary function is reduced, and more mucus function is reduced, and more mucus is produced.is produced.

Bronchial walls become thickened Bronchial walls become thickened resulting in narrowing of lumen, and resulting in narrowing of lumen, and mucus may plug the airway.mucus may plug the airway.

Adjacent alveoli may become Adjacent alveoli may become damaged and fibrosed, resulting in damaged and fibrosed, resulting in altered function of alveolar altered function of alveolar macrophages. As a result the client macrophages. As a result the client becomes more susceptible to becomes more susceptible to respiratory infectionrespiratory infection

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

COPD- emphysemaCOPD- emphysema

An abnormal distention of the air An abnormal distention of the air spaces beyond the terminal spaces beyond the terminal bronchioles with destruction of the bronchioles with destruction of the walls of the alveoliwalls of the alveoli

Commonly caused by smokingCommonly caused by smoking Protein breakdown is the villain Protein breakdown is the villain

which causes erosion of the alveolar which causes erosion of the alveolar system, dilation of distal air spaces system, dilation of distal air spaces and destruction of elastic fibersand destruction of elastic fibers

Alveoli lose their elastic recoil, Alveoli lose their elastic recoil, then weaken and rupture.then weaken and rupture.

Air remains trapped in the lungs, Air remains trapped in the lungs, (formation of air pockets or (formation of air pockets or bullae); carbon dioxide bullae); carbon dioxide accumulates (hypercapnia) with accumulates (hypercapnia) with resulting respiratory acidosisresulting respiratory acidosis

Cor pulmonale is one of the Cor pulmonale is one of the complications of emphysemacomplications of emphysema

Client with emphysema tries to Client with emphysema tries to maintain near normal blood maintain near normal blood gases at the expense of gases at the expense of brathlesness and weight loss, brathlesness and weight loss, no cyanosis occurs (pink no cyanosis occurs (pink puffers)puffers)

The flat diaphragm works The flat diaphragm works paradoxically and becomes paradoxically and becomes expiratory in action, thus, expiratory in action, thus, drawing the lower ribs in drawing the lower ribs in inspiration ( Hoover’s sign)inspiration ( Hoover’s sign)

Types of EmphysemaTypes of Emphysema Centrolobar EmphysemaCentrolobar Emphysema

Affects the respiratory bronchiolesAffects the respiratory bronchioles Most common type of emphysemaMost common type of emphysema Associated with chronic bronchitis Associated with chronic bronchitis

and bronchial inflammationand bronchial inflammation Originates at the center of the lobule Originates at the center of the lobule

and is distinct from the periphery of and is distinct from the periphery of the acinus with its septae and vesselsthe acinus with its septae and vessels

Variable and patchy and has a Variable and patchy and has a predilection for upper lung zonespredilection for upper lung zones

Panlobar or panacinar Panlobar or panacinar emphysemaemphysema Associated with severe alpha 1- Associated with severe alpha 1-

antitrypsin defeciency and affects antitrypsin defeciency and affects the alveoli themselves, causing the alveoli themselves, causing more destruction.more destruction.

Little association with chronic Little association with chronic bronchitis bronchitis

Clinical syndrome of COPDClinical syndrome of COPD

Patients with empysematous, Patients with empysematous, dyspneic or Type A COPD are dyspneic or Type A COPD are referred as PINK PUFFERSreferred as PINK PUFFERS

Those with bronchitic, tussive or Those with bronchitic, tussive or Type B COPD are referred as Type B COPD are referred as BLUE BLOATERSBLUE BLOATERS

Pink puffersPink puffers Have predominant emphysemaHave predominant emphysema Symptoms of relatively advanced age Symptoms of relatively advanced age

( >60 yrs)( >60 yrs) Progressive exertional dyspnea, weight Progressive exertional dyspnea, weight

loss, little or no cough and expectoration.loss, little or no cough and expectoration. Mild hypoxia, hypocapnia and little Mild hypoxia, hypocapnia and little

improvement in airflow after treatment improvement in airflow after treatment with bronchodilators. They usually with bronchodilators. They usually undergo a slowly progressive downhill undergo a slowly progressive downhill coursecourse

Blue BloatersBlue Bloaters Predominant chronic bronchitisPredominant chronic bronchitis At relatively young ageAt relatively young age Chronic cough and expectoration, Chronic cough and expectoration,

episodic dyspnea and weight gainepisodic dyspnea and weight gain Wheezing and ronchi, cor pulmonale, Wheezing and ronchi, cor pulmonale,

accompanied by edema and cyanosisaccompanied by edema and cyanosis Severe hypoxia, hypercapnia, Severe hypoxia, hypercapnia,

polycythemiapolycythemia Improvede airflow after treatment with Improvede airflow after treatment with

bronchodilators and relatively preserved bronchodilators and relatively preserved lung volumes.lung volumes.

Nursing implementation for Nursing implementation for COPDCOPD Monitor vital signsMonitor vital signs Administer a low concentration Administer a low concentration

of oxygen (2-3 L/min) as of oxygen (2-3 L/min) as prescribed ; in emphysema, the prescribed ; in emphysema, the stimulus to breathe is a low PO2 stimulus to breathe is a low PO2 instead of an increased in PCO2instead of an increased in PCO2

Monitor pulse oximetryMonitor pulse oximetry Provide respiratory treatments Provide respiratory treatments

and chest physiotherapyand chest physiotherapy

Instruct the client in Instruct the client in diaphragmatic or abdominal and diaphragmatic or abdominal and pursed-lip breathing techniquespursed-lip breathing techniques

Record the color, amount and Record the color, amount and consistency of sputumconsistency of sputum

Suction the client, if necessary , Suction the client, if necessary , to clear airway and prevent to clear airway and prevent infectioninfection

Monitor weightMonitor weight Encourage small frequent meals Encourage small frequent meals

to prevent dyspneato prevent dyspnea

Provide high CHO and high CHON Provide high CHO and high CHON diet with supplementsdiet with supplements

Encourage fluids up to 3000 ml/day Encourage fluids up to 3000 ml/day to keep secretions thin unless to keep secretions thin unless contraindicatedcontraindicated

Position in high fowler’s or Position in high fowler’s or orthopneic position orthopneic position

Allow activity as toleratedAllow activity as tolerated Administer bronchodilators as Administer bronchodilators as

prescribed and instruct the client in prescribed and instruct the client in the use of both oral and inhalant the use of both oral and inhalant medicationsmedications

Administer corticosteroids as Administer corticosteroids as prescribed to reduce prescribed to reduce inflammationinflammation

Administer mucolytics as Administer mucolytics as prescribed to thin secretionsprescribed to thin secretions

Administer antibiotics for Administer antibiotics for infection as prescribedinfection as prescribed

Coping measures:Coping measures: Patients experience anxiety, Patients experience anxiety,

apprehension, frustration of apprehension, frustration of having to work to breathehaving to work to breathe

Adapt a hopeful and encouraging Adapt a hopeful and encouraging attitudeattitude

Emphasis should be in controlling Emphasis should be in controlling his symptoms and increasing self his symptoms and increasing self esteem and sense of mastery and esteem and sense of mastery and well-beingwell-being

Patient education and home Patient education and home health care:health care: Stop smokingStop smoking Tell him what to expect. He and Tell him what to expect. He and

family caring for him will need family caring for him will need patiencepatience

Help patient accept set realistic Help patient accept set realistic short term and long term goalsshort term and long term goals

The objective is to increase The objective is to increase exercise tolerance and prevent exercise tolerance and prevent further loss of pulmonary functionfurther loss of pulmonary function

Educate the patient about the Educate the patient about the disease processdisease process

Recognize the signs and Recognize the signs and symptoms of respiratory infection symptoms of respiratory infection and hypoxiaand hypoxia

Adhere to activity limitations, Adhere to activity limitations, altering rest periods with activityaltering rest periods with activity

Avoid exposure to individuals with Avoid exposure to individuals with infections and avoid crowdsinfections and avoid crowds

Instruct to avoid extremes of heat Instruct to avoid extremes of heat and coldand cold

Demonstrate pursed-lip and Demonstrate pursed-lip and diaphragmatic or abdominal diaphragmatic or abdominal breathingbreathing

Instruct the client in the use of Instruct the client in the use of medications and inhalersmedications and inhalers

Instruct the client in the use of Instruct the client in the use of oxygen therapyoxygen therapy

Instruct the client in nutritional Instruct the client in nutritional requirementsrequirements

Avoid eating gas-producing foods, Avoid eating gas-producing foods, spicy foods, and extremely hot and spicy foods, and extremely hot and cold foodscold foods

Instruct in the importance of Instruct in the importance of receiving immunizations as receiving immunizations as recommendedrecommended

When dusting , use a wet clothWhen dusting , use a wet cloth Avoid powerful odorsAvoid powerful odors Avoid extremes in temperatureAvoid extremes in temperature Avoid fireplaces, pets, and Avoid fireplaces, pets, and

feather pillowsfeather pillows

AsthmaAsthma

An intermittent reversible airway An intermittent reversible airway obstruction characterized by obstruction characterized by hyperresponsiveness or hyperresponsiveness or heperirritability and heperirritability and inflammation of the airwaysinflammation of the airways

Substances that have no effect Substances that have no effect when inhaled by normal when inhaled by normal individuals can cause individuals can cause bronchoconstrictions in patients bronchoconstrictions in patients with asthmawith asthma

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

Allergy is the strongest Allergy is the strongest predisposing factor for asthma predisposing factor for asthma

Incidence and etiology:Incidence and etiology:

Asthma occurs in 3-8 % of the Asthma occurs in 3-8 % of the populationpopulation

It is traditionally divided into 3 It is traditionally divided into 3 formsforms An allergic form – extrinsic formAn allergic form – extrinsic form An intrinsic formAn intrinsic form Mixed asthmaMixed asthma

Extrinsic (allergic)

Intrinsic (infectious / miscellaneous)

Age of Onset 3- 35 y.o Under 3, over 35-40

Symptoms Season of perennial, frequently pollen and mold related

Worse in winter, cold seasons, exacerbated by cold air, air pollution, and primarily by infection

Mucus Clear and foamy Thick and white or discolored

Family History positive No greater than in general population

Skin Tests Positive and correlating

Negative or positive non-correlating

Serum Ig E High or normal normal

Response to therapy

Good response to immunotherapy and bronchodilator

Poor response to bronchodilators, no response to immunotherapy

The following may trigger an The following may trigger an asthma attack:asthma attack: Allergenic foods (eggs, nuts, wheat, Allergenic foods (eggs, nuts, wheat,

dairy products)dairy products) Chest infectionChest infection Drugs e.g. NSAIDS, ASADrugs e.g. NSAIDS, ASA ExerciseExercise Car exhaustCar exhaust ExerciseExercise Frustrated expression of emotionFrustrated expression of emotion PremenstruationPremenstruation PollenPollen

SmokingSmoking Warm blooded petsWarm blooded pets WeatherWeather

Education about these risk Education about these risk factors and prevention is vital in factors and prevention is vital in care of patients in asthmacare of patients in asthma

Biochemical mediatorsBiochemical mediators

Ig E cell mediated, histamine Ig E cell mediated, histamine from mast cellsfrom mast cells

Serotonin, prostaglandins, Serotonin, prostaglandins, thromboxanes, thromboxanes, endoperoxidases, also cause endoperoxidases, also cause tissue inflammation and maybe tissue inflammation and maybe particularly important in the particularly important in the pathogenesis of nonallergic pathogenesis of nonallergic asthma asthma

Pathophysiologic basis:Pathophysiologic basis:

Get a whole sheet of paperGet a whole sheet of paper Make a tracing of the Make a tracing of the

pathophysiology of asthma pathophysiology of asthma using your book.using your book.

Other classification of asthma Other classification of asthma and their clinical featuresand their clinical features

Mild chronic asthmaMild chronic asthma -manifests an intermittent dry -manifests an intermittent dry

cough often at night or morning cough often at night or morning and wheezes once or twice a and wheezes once or twice a weekweek

Severe Chronic AsthmaSevere Chronic Asthma

-frequent exacerbations and -frequent exacerbations and symptoms that significantly affect symptoms that significantly affect quality of lifequality of life

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

Acute asthma- Acute asthma- large airways are large airways are obstructed by bronchospasm and the obstructed by bronchospasm and the small airways by edema and mucus small airways by edema and mucus plugging.plugging.

Associated with breathlessness, Associated with breathlessness, rapid breathing and abdominal rapid breathing and abdominal paradoxparadox

Severe acute asthmaSevere acute asthma Most commonly develops slowly, Most commonly develops slowly,

often after several weeks of often after several weeks of wheezingwheezing

Alternately, attack is sudden, Alternately, attack is sudden, especially if there has been poor especially if there has been poor drug controldrug control

Can be fatal within minutesCan be fatal within minutes

Status asthmaticusStatus asthmaticus

Severe asthma attacked Severe asthma attacked prolonged over 24 hours.prolonged over 24 hours.

Clinical manifestations include Clinical manifestations include fatigue, PR > 100bpm and fatigue, PR > 100bpm and cyanosiscyanosis

Use of accessory musclesUse of accessory muscles Pulsus paradoxus Pulsus paradoxus

Exercise – induced asthmaExercise – induced asthma -hyperventilation during exercise, -hyperventilation during exercise,

especially in cold weather causes especially in cold weather causes bronchospasm bronchospasm

Nocturnal asthma- 80% in Nocturnal asthma- 80% in asthmaticsasthmatics -interferes with sexual intercourse -interferes with sexual intercourse

and sleepingand sleeping Occupational asthmaOccupational asthma

-may take weeks or years to -may take weeks or years to developdevelop

Diagnosis:Diagnosis:

Sputum analysisSputum analysis -may appear purulent-may appear purulent -reveal Curschmann’s spirals-reveal Curschmann’s spirals - reveals Charcot’s Layden crystals - reveals Charcot’s Layden crystals

Hematologic studies- modest Hematologic studies- modest leukocytosis and eosinophilialeukocytosis and eosinophilia

Pulmonary function testingPulmonary function testing Chest x-rayChest x-ray

ABG studies- PCO2 is low less ABG studies- PCO2 is low less that 36 mmHg. An increased that 36 mmHg. An increased PCO2 or normal PCO2 indicates PCO2 or normal PCO2 indicates severe obstruction severe obstruction

Nursing Assessment:Nursing Assessment: CoughCough DyspneaDyspnea WheezingWheezing DiaphoresisDiaphoresis TachycardiaTachycardia General chest tightnessGeneral chest tightness HypoxemiaHypoxemia Central cyanosisCentral cyanosis History- + family hx- periodic reversible History- + family hx- periodic reversible

airflow obstructionairflow obstruction

Nursing Implementation:Nursing Implementation: Assess airway patencyAssess airway patency Elevate headElevate head Administer humidified O2Administer humidified O2 Continuously monitor resp status:Continuously monitor resp status:

Give Medications as prescribed Give Medications as prescribed (Bronchodilators)(Bronchodilators)

Sympathomimetics ( B2 agonists)Sympathomimetics ( B2 agonists) Methlyxanthines (Theophylline)Methlyxanthines (Theophylline) Anti cholinergic agents (Ipratropium) Anti cholinergic agents (Ipratropium)

DO NOT GIVE BETA DO NOT GIVE BETA BLOCKERS!!!!!BLOCKERS!!!!!

Anti-inflammatory agents:Anti-inflammatory agents: Corticosteroids and cromolyn Corticosteroids and cromolyn

sodiumsodium

Prevent exacerbationsPrevent exacerbations Teaching: Teaching:

PositioningPositioning Pursed-lip exercisesPursed-lip exercises Nutrition: Avoid over feeding!Nutrition: Avoid over feeding!