Asthma Mechanisms and Pathophysiology Quiz

Care of Clients with Problems in Oxygenation

• This presentation is about the care of clients with oxygenation problems. Several topics are covered, including upper and lower respiratory tract disorders, chronic pulmonary disease, and allergic rhinitis.

Respiratory Systems Disorder - Management of Patients with Upper Respiratory Tract Disorders

• Nursing management of patients with upper airway disorders is described.
• Upper respiratory tract infections (URTIs) are discussed, including causes, incidence, clinical manifestations, and management.
• The nursing process is explained in caring for patients with upper airway infections.

Respiratory Systems Disorder - Management of Patients with Chest and Lower Respiratory Tract Disorders

• Various pulmonary infections are compared, including causes, clinical manifestations, nursing management, complications, and prevention.
• Preventive measures against occupational lung diseases are described.

Respiratory Systems Disorder - Management of Patients with Chronic Pulmonary Disease

• The pathophysiology, clinical manifestations, treatment, and medical/nursing management of chronic pulmonary diseases are discussed.
• Major risk factors for chronic obstructive pulmonary disease (COPD) are identified, along with nursing interventions to minimize or prevent these risks.
• An education plan for patients with COPD is developed.

Upper Respiratory Disorders

• This section focuses on upper respiratory disorders, specifically rhinitis.

Types of Rhinitis

• Allergic rhinitis is a reaction of the nasal mucosa to a specific allergen. Classification is based on the causative allergen (seasonal or perennial) or frequency of symptoms (episodic, intermittent, or persistent).
• Episodic rhinitis involves symptoms related to sporadic exposure to allergens not typically found in the patient's environment. For instance, exposure to animal dander in another person's home.
• Intermittent rhinitis means symptoms are present less than 4 days a week or less than 4 weeks per year.
• Persistent rhinitis means symptoms are present more than 4 days a week and for more than 4 weeks per year.

Pathophysiology

• Sensitization to allergens occurs with initial exposure, leading to the production of antigen-specific immunoglobulin E (IgE).
• After exposure, mast cells and basophils release histamine, cytokines, prostaglandins, and leukotrienes, leading to sneezing, itching, rhinorrhea, and congestion.
• Four to eight hours after exposure, inflammatory cells infiltrate the nasal tissues, causing and maintaining the inflammatory response.
• Symptoms of rhinitis resemble the common cold, potentially misdiagnosed as such.

Clinical Manifestations

• Initial manifestations of allergic rhinitis include sneezing, watery/itchy eyes and nose, altered sense of smell, and watery nasal discharge, potentially leading to nasal congestion.
• Nasal turbinates may appear pale, boggy, and swollen.
• Cardinal symptoms include watery rhinorrhea, nasal obstruction, nasal itching, and sneezing.
• Posterior ends of turbinates can enlarge, obstructing sinus aeration and potentially leading to sinusitis.
• Chronic allergen exposure may result in headaches, congestion, pressure, nasal polyps, and postnasal drip, often causing cough.
• Recurrent throat clearing and cough may also occur due to congestion.

Diagnosis of Allergic Rhinitis

• Diagnosis is based on a patient history of allergic symptoms and various diagnostic tests.
• If two or more symptoms, such as watery rhinorrhea, sneezing, nasal obstruction, and nasal pruritus persist for at least an hour most days, allergic rhinitis is highly suspected.
• Skin testing is crucial for identifying offending allergens, with methods including scratch, prick, puncture, intradermal, and patch tests.
• Radioallergosorbent tests (RAST) and multiple allergen simultaneous tests (MAST) aid in diagnosis.

Treatment of Allergic Rhinitis

• Treatment requires a stepwise approach based on symptom severity and duration.
• Treatment options involve allergen avoidance, pharmacotherapy, immunotherapy, and sometimes surgery.
• Common categories of medications for managing cold symptoms include antihistamines, decongestants, antitussives, and expectorants.

Pharmacotherapy

• Over-the-counter (OTC) non-sedating antihistamines competitively inhibit the interaction of histamine with H1 receptors.
• These prevent and relieve nasal itching, sneezing, rhinorrhea, and ocular symptoms. Examples include Loratadine (10 mg once daily), Desloratadine (5 mg once daily), Cetirizine (10 mg once daily or divided BID), and Levocetirizine (5 mg once daily in the evening)

Intranasal Corticosteroids

• Intranasal corticosteroids are potent inhibitors of the late-phase allergic reaction.
• They inhibit the recruitment of Langerhans cells, macrophages, mast cells, T cells, and eosinophils into the nasal mucosa.
• Intranasal steroids control itching, sneezing, rhinorrhea, and stuffiness. For example Beclomethasone (2 sprays EN/day) and Fluticasone (Flonase) (1-2 sprays EN/day).

Decongestants

• Decongestants decrease nasal mucosa swelling to alleviate nasal congestion. Oxymetazoline nasal spray and Pseudoephedrine pills are examples.

Nursing and Collaborative Management

• The most crucial step in managing allergic rhinitis is identifying and avoiding allergic reaction triggers.
• Medications aim to reduce inflammation associated with allergic rhinitis, lessen nasal symptoms, minimize complications and maximizing quality of life.
• Oral medications options include H1-antihistamines, corticosteroids, decongestants, and leukotriene receptor antagonists (LTRAs).
• Second-generation antihistamines are preferred over first-generation ones due to lack of sedative effects.
• Patients taking antihistamines should drink enough fluids to reduce side effects.
• Intranasal corticosteroid sprays are used to locally decrease inflammation and have minimal systemic side effects.

Non-Allergic Rhinitis

• Non-allergic rhinitis is independent of IgE and not an allergic reaction.
• Triggers include cigarette smoke, air pollutants, strong odors, alcoholic beverages, and colds.
• Other causes encompass nasal blockages, deviated septa, infections, and overuse of decongestants.

Acute Viral Rhinitis

• Acute viral rhinitis (common cold) is an upper respiratory tract infection caused by more than 200 viruses, most commonly rhinoviruses.
• Colds are generally mild and self-limiting, with symptoms lasting 2 to 14 days, and typical recovery in 7 to 10 days.
• Patients should use intranasal decongestant sprays for a maximum of three days to avoid rebound congestion.
• Cough suppressants may be used.
• Complications can include pharyngitis, sinusitis, otitis media, tonsillitis, and lung infections.
• Antibiotics are not typically indicated unless specific complications manifest.
• Lengthy symptoms (more than 10–14 days) without improvement may suggest bacterial sinusitis. Teaching the patient to recognize the symptoms of secondary bacterial infection is important. These symptoms include temperature higher than 100.4°F (38°C), swollen tender glands, severe sinus or ear pain, or worsening symptoms.

Sinusitis

• Sinusitis is an inflammatory process in one or more paranasal sinuses. It is a common complication in URTIs (5%-10% incidence in children) Persistent symptoms without improvement for more than 10-14 days suggest possible bacterial sinusitis. Four pairs of paranasal sinuses are identified in the head: frontal, maxillary, ethmoid, and sphenoid.

Pathophysiology of Sinusitis

• Rhinitis or abrupt pressure changes (air travel), dental extractions, or inflmmation can cause sinus obstruction.
• Mucosal lining produces mucoid drainage that can be invaded by bacteria, leading to pus accumulation inside the sinus cavities and postnasal drainage.
• Blockages of sinus orifices by swollen mucosal lining prevent mucus drainage, creating pressure buildup in the sinus cavities.

Predisposing Factors for Sinusitis

• Allergies, cold weather, high pollen counts, day care attendance, smoking in the home, and re-infections from siblings are potential predisposing factors.
• Anatomical factors such as septal deviation, nasal deformities, and nasal polyps also increase risks.
• Underlying immune deficiencies (DM or AIDS) and neoplasia can increase risk.

Etiology of Sinusitis

• Bacterial and viral infections are common causes of acute sinusitis, differing in prevalence.
• Specific bacterial and viral agents are listed.

Signs and Symptoms of Sinusitis

• Common signs and symptoms of sinusitis include headache, congestion, facial pain, fatigue, cough, and purulent nasal discharge. Facial pain location can assist in identifying the specific sinus affected (maxillary, ethmoid, or frontal).
• Fever may accompany acute infections.

Diagnosis of Sinusitis

• Chronic sinusitis is characterized by prolonged symptoms exceeding 120 days. A persistent history of URI and physical findings guide the diagnosis.
• Radiographic studies like X-rays, CT scans, and MRIs confirm the presence, extent, and type of infection.
• Translumination of sinus cavities, sinus aspirate cultures, and nasal endoscopy are additional diagnostic tools.

Treatment of Sinusitis

• Nondrug measures include maintaining adequate hydration, using a personal steam vaporizer, applying warm facial compresses, saline irrigation, and elevating the head of the bed for drainage.
• Appropriate drugs of choice for acute bacterial sinusitis include various antibiotics.

Tonsillitis

• Tonsils, lymph glands on either side of the throat, are vital immune system components. Protection is offered by fighting pathogens (bacteria and viruses) as soon as they enter the body (oral/nasal cavity).
• Tonsillitis is an inflammatory process of the pharyngo-tonsillar area, often infectious.
• Tonsillitis is contagious and prevalent in children between the ages of five and ten.

Clinical Manifestations of Tonsillitis

• Common clinical features include sore throat (mild to severe), difficulty swallowing (odynophagia), pharyngeal exudate, anterior cervical lymphadenopathy, scarlet fever rash, headache, chills and fever (up to 104°F or 40°C), swollen lymph nodes on either side of the jaw, ear pain, and potentially vomiting. Young children may refuse food. Possible symptoms include redness, edema, ulcers, or vesicles in the throat.

Causes of Tonsillitis

• Viral infections (rhinovirus, adenovirus, influenza, parainfluenza, coxsackie, and Epstein-Barr viruses) are the most common causes of tonsillitis.
• Bacterial infections such as group A beta-hemolytic streptococcus (GABHS) and other streptococcal species, Neisseria gonorrhoeae, and Corynebacterium diphtheriae.
• Yeast species (Candida) and spirochetes (Treponema pallidum, syphilis) can also cause tonsillitis.

Assessment and Diagnostic Findings of Tonsillitis

• A physical examination of the throat, noting swollen or red tonsils with spots or sores, helps in diagnosis.
• Throat cultures, rapid strep tests, and blood tests can confirm the presence of infection.

Medical Management of Tonsillitis

• Bed rest, except for bathroom use, is necessary until fever subsides.
• Supportive measures include increased fluid intake and liquid nourishment (milk shakes, soups, high-protein drinks) if the throat is sore.
• Viral tonsillitis does not respond to antibiotic therapy.
• Tonsillectomy may be necessary for complicated tonsillitis cases.

Antibiotic Treatment of Choice for Tonsillitis

• Penicillin V, at dosages based on age and weight, is the antibiotic of choice for tonsillitis.
• Alternative regimens may include amoxicillin, azithromycin, or clindamycin, depending on the specific causative agent and allergy concerns.

Indications for Tonsillectomy

• Recurrent tonsillitis (more than seven infections per year)
• Chronic tonsillitis
• Recurrent peritonsillar abscesses
• Unilateral tonsillar hypertrophy
• Hemorrhagic tonsillitis
• Chronic tonsillolithiasis (stone formation in tonsils)

Complications of Tonsillitis

• Suppurative: peritonsillar, parapharyngeal, and retropharyngeal abscess formation
• Nonsuppurative: scarlet fever, acute rheumatic fever, post-streptococcal glomerulonephritis

Acute Pharyngitis

• Acute pharyngitis, commonly known as a sore throat, refers to a sudden painful inflammation of the pharynx, which includes the posterior third of the tongue, soft palate, and tonsils.
• The most common causes are viral infections (adenovirus, influenza, Epstein-Barr virus, and herpes simplex virus), and bacterial infections (group A beta-hemolytic streptococcal infection, also known as strep throat).

Pathophysiology of Acute Pharyngitis

• Viral or strep throat infection triggers an inflammatory response in the pharynx.
• The inflammatory response manifests as pain, fever, vasodilation, edema, and tissue damage, characterized by redness and swelling in the tonsillar pillars, uvula, and soft palate.
• A creamy exudate may be present in the tonsillar pillars, particularly in bacterial cases.
• Viral infections typically subside within 3 to 10 days of onset.

Complications of Acute Pharyngitis

• Sinusitis, otitis media, peritonsillar abscess, mastoiditis, cervical adenitis, bacteremia, pneumonia, meningitis, and rheumatic fever/ nephritis are possible complications.

Laryngitis

• Laryngitis is inflammation in the larynx (voice box), causing edema of the laryngeal mucosa and surrounding structures.

Etiology of Laryngitis

• Viral laryngitis is often caused by rhinovirus, influenza, parainfluenza, adenovirus, coronavirus, and Respiratory Syncytial Virus (RSV).
• Bacterial laryngitis can stem from group A Streptococcus, Streptococcus pneumoniae, Corynebacterium diphtheriae, Haemophilus influenzae, Bordetella pertussis, and Mycobacterium tuberculosis.
• Fungal infections like Histoplasma and Candida, especially in immunocompromised individuals, may also cause laryngitis.
• Noninfectious causes include inhaled fumes, acid reflux disease, allergies, excessive coughing/smoking/alcohol consumption, vocal cord overuse, prolonged use of inhaled corticosteroids, and laryngeal trauma.

Predisposing Factors of Laryngitis

• Common predisposing factors for laryngitis include smoking, psychological strain, physical stress, voice misuse, acid reflux (GERD), and frequent sinus infections.

Pathophysiology of Laryngitis

• Etiological factors lead to congestion and edema of the laryngeal mucosa.
• Fibrinous exudates may form on the surface.
• Infection might extend to the perichondrium of laryngeal cartilages, potentially causing perichondritis.

Types of Laryngitis

• Acute laryngitis lasts less than a few days & leads to edema of laryngeal mucosa & underlying structures.
• Chronic laryngitis, lasting over 3 weeks, often results in lingering hoarseness and other voice changes. It is typically painless and presents minimal signs of infection.

Clinical Features of Laryngitis

• Common symptoms encompass husky, high-pitched voice, body aches, fever, malaise, dysphonia (hoarseness or inability to speak), dysphagia (difficulty swallowing), dyspnea (difficulty breathing, especially in children), dry/burning throat, irritating cough, cold-like symptoms (runny nose, sore throat), swollen lymph nodes, hoarseness, and potentially hemoptysis (coughing up blood) and increased saliva. Specific signs include dry, thick, sticky secretions and dusky, red, swollen vocal cords.

Diagnostic Methods for Laryngitis

• Diagnosis is usually based on a combination of patient history and physical examination.
• Severe cases (particularly in children) might necessitate neck and chest X-rays and a complete blood count (CBC).
• Laryngoscopy—with a direct visual examination of the vocal cords using a tiny mirror and light—might be employed.
• Obtaining a tissue biopsy might be necessary.

Medical Management of Laryngitis

• Supportive care often involves voice rest, steam inhalation, cough suppressants, avoidance of smoking and exposure to cold/dry environments, adequate fluid intake.
• Definitive treatments address the underlying cause. H2-receptor blockers or proton-pump inhibitors are suitable for gastroesophageal reflux cases. Steroids are used for thermal or chemical burns. Addressing bacterial or fungal infections necessitates suitable antibiotic or antifungal therapies.

Supportive Therapy for Laryngitis

• Adequate hydration with plenty of fluids, herbal teas, and chicken soup, are soothing.
• Regular exercise enhances general health. Avoiding smoking and cold exposure maintain good lung function.
• A balanced diet with fruits, vegetables, and whole grains ensures nutritional support.
• Avoiding dry, artificial environments and consuming foods at appropriate times helps prevent stomach acid from reaching vocal cords. A humidifier aids hydration.

Management of Patients with Respiratory Disorders - Oxygen Therapy

• Oxygen therapy involves administering oxygen at a concentration exceeding the normal environmental atmosphere (typically 21% at sea level).
• Oxygen is used to improve respiratory transport, lower work of breathing, and reduce myocardium stress to manage hypoxemia (change in respiratory rate or pattern) or hypoxia.
• Oxygen administration is assessed through arterial blood gas analysis and pulse oximetry along with clinical evaluation.

Indications for Oxygen Therapy

• Changes in respiratory rate and/or pattern, which often indicate hypoxemia or hypoxia, are strong indications for oxygen therapy.
• The need for supplemental oxygen is assessed through arterial blood gas analysis, pulse oximetry, and clinical evaluation. Signs and symptoms include: confusion, lethargy, coma, dyspnea, increased blood pressure, dysrhythmias, central cyanosis (late sign), diaphoresis, and cool extremities.

Oxygen Toxicity

• High oxygen concentrations (over 50%) for extended periods can result in oxygen toxicity.
• Overproduction of oxygen free radicals can severely damage cells.
• Antioxidants (vitamin E, vitamin C, and beta-carotene) can counteract these effects.

Suppression of Ventilation

• In patients with COPD, the stimulus for respiration depends more on decreased blood oxygen than increased carbon dioxide levels.
• Administering high concentrations of oxygen removes the breathing drive, potentially causing a decrease in alveolar ventilation.
• This can raise arterial CO2 (PaCO2) pressure, ultimately leading to potentially fatal carbon dioxide narcosis or acidosis.

Other Complications of Oxygen Therapy

• Oxygen supports combustion, therefore, no smoking signs should be posted when oxygen is in use due to the risk of fire.
• Oxygen delivery equipment can carry bacteria therefore nurses must utilize appropriate infection control precautions and policy.

Methods of Oxygen Administration

• Oxygen delivery systems are classified into low-flow (nasal cannula, simple mask, partial rebreather mask, and nonrebreather mask) or high-flow systems (Venturi masks, tracheostomy collars, tracheal catheters, and face tents) based on the intended oxygen concentration and the patient's individualized breathing pattern.
• Low-flow is partial to the patient's breath. This varies with breathing changes. High-flow administration provides a constant concentration of oxygen.

Chest Physiotherapy

• Chest physiotherapy (CPT) involves postural drainage, chest percussion, and vibration, alongside breathing retraining techniques.
• Aims to clear bronchial secretions, improve ventilation, and enhance the efficiency of respiratory muscles.

Postural Drainage

• Facilitated by gravity and usually performed before meals and at bedtime.
• It drains secretions from affected bronchioles to bronchi & trachea through coughing or suctioning, preventing or relieving bronchial obstructions related to secretion accumulation.

Positions used for Postural Drainage

• Multiple positions are used to drain different lung lobes and segments, typically employing upright or inclined positions.

Nursing Management for Postural Drainage

• Nurses must assess the patient's diagnosis and status (including respiratory and cardiac), look for potential chest wall or spine irregularities, and auscultate the chest before and after postural drainage procedures to assess drainage effectiveness.
• Strategies for patient positioning at home must factor in use of everyday objects such as pillows, cushions, and cardboard boxes.

Deep Breathing and Coughing

• Effective coughing helps clear secretions and airway problems.
• Patients are taught proper diaphragmatic breathing, followed by forceful exhalation, to clear bronchial secretions.
• Enough fluid intake facilitates the procedure.

Incentive Spirometry

• Incentive spirometry (also known as sustained maximal inspiration) mimics natural sighing and promotes deep breathing in patients by utilizing devices that provide visual feedback for pre-determined flow or volume, maintaining the inhalation for five seconds.

Purpose of Incentive Spirometry

• The procedure aims to increase transpulmonary pressure and inspiratory volumes, improving inspiratory muscle function, and reestablishing or simulating normal pulmonary hyperinflation patterns.
• Repetitions keep airways open, preventing lung atelectasis.

Indications for Incentive Spirometry

• Upper/lower abdominal or thoracic surgery
• Prolonged bed rest
• COPD
• Lack of pain control
• Presence of thoracic or abdominal binders

Using an Incentive Spirometer

• Patients use the spirometer by assuming a sitting or semi-Fowler's position, using their diaphragm for breathing. They must breathe in deeply then hold their breath for 3-4 seconds and exhale slowly, repeating 6–10 times per session.
• Spirometer use should be frequent, especially during periods of waking hours. Coughing is encouraged after each process to assist.

Artificial Airways

• Artificial airways, like endotracheal tubes (ETTs) and tracheostomy tubes are utilized to ensure adequate airflow for patients who cannot maintain their own airway function, such as those in a coma or with airway obstruction.
• Patients requiring ETTs for 10 days or less, and those requiring at least 21 days of intubation, should typically receive a tracheostomy tube.

Disadvantages of Artificial Airways

• ETTs or tracheostomy tubes cause discomfort, suppress cough reflex from hindering glottis closure.
• Secretions might thicken due to bypass of upper respiratory tract's warming and humidification mechanisms.
• Prolonged use might cause swallowing reflex depression, and potential issues with throat/trachea ulcerations or strictures. Inability to speak and communicate needs is also a concern.

Endotracheal Intubation

• Endotracheal intubation is a procedure to insert an endotracheal tube through the mouth or nose into the trachea.
• It is a method to provide an airway to comatose patients, patients with upper airway obstructions, and those needing mechanical ventilation.
• Suctioning secretions from the pulmonary tree can also be facilitated.

Tracheostomy

• Tracheostomy is a surgical procedure for establishing an opening into trachea.
• Surgical procedure to make an opening in the trachea and inserts an indwelling tube, called a tracheostomy tube.
• Tracheostomy tubes can be temporary or permanent. Necessary equipment includes sterile gloves, hydrogen peroxide, normal saline, cotton-tipped applicators, dressing material and twill tape.

Tracheostomy Tube Use

• Bypass upper airway obstruction.
• Facilitates secretion removal.
• Permit long-term mechanical ventilation.
• Prevent aspiration in unconscious/paralyzed patients.
• Replace endotracheal tubes.

Nursing Management for Artificial Airways

• Continuous monitoring and patient assessment is necessary.
• Maintaining airway patency through appropriate suctioning of secretions is also required.
• Patient positioning (semi-Fowler's positioning) facilitates better ventilation and reduces edema or strain on suture lines.
• Administer analgesics & sedatives with caution to prevent suppression of the cough reflex.

Preventing Complications Associated with Endotracheal and Tracheostomy Tubes

• Monitor and maintain appropriate warmed humidification.
• Maintain proper cuff pressure.
• Suction secretions are necessary.
• Maintain skin integrity, changing tape/dressing as needed.
• Auscultate lung sounds and monitor for infection signs such as temperature and white blood cell counts.
• Provide adequate hydration
• Monitor for cyanosis and provide prescribed oxygen.
• Use sterile technique when performing suctioning and tracheostomy care.

Lower Respiratory Tract Disorders

• This section is about lower respiratory tract conditions, such as pneumonia and COPD.

Pneumonia

• Pneumonia is an infection/inflammation in the lower respiratory tract (bronchioles and alveoli). Bacterial/viral infections are common causes.
• Pneumonia causes lung inflammation in the parenchyma (tissue) and air sacs.
• Pneumonitis is immune-mediated inflammation of the alveoli.

Clinical Definition of Pneumonia

• Symptoms of acute lower respiratory tract (LRT) infection, including cough (greenish/yellow sputum), fever, chest pain, sweating, chills/aches are indicators.
• Other significant indicators are new focal chest signs during physical examination or new radiographic pulmonary infiltrates (evidenced by X-rays).

Classification of Pneumonia

• Pneumonia classification depends on causative agents such as bacterial (typical), atypical, viral, or fungal pneumonia.
• Anatomically, lobar pneumonia exhibits homogenous consolidation in one or more lung lobes, while bronchopneumonia shows multiple patchy shadows in localized or segmental areas.

Bronchopneumonia

• Infants, young children, and the elderly are more susceptible to bronchopneumonia.
• Predisposing factors include conditions causing reduced local or overall immune defenses.
• Possible causes include viral infections (influenza, measles), food or vomit aspiration, Bronchus obstruction (foreign bodies/tumors), inhalation of irritants, major surgeries, chronic debility/ malnutrition.

Lobar Pneumonia

• Lobar pneumonia affects one or more complete lung lobes. Infections typically onset sharply with previously healthy individuals. Notable presentations include unilateral stabbing chest pain during inhalation (resulting from fibrinous pleurisy)

Community-acquired Pneumonia (CAP)

• Infection affecting the lung's respiratory parenchyma (tissue) is community-acquired.
• Occurs primarily in the community setting or within 48 hours of hospitalization/institutionalization, often transmitted through droplet inhalation.
• Occurring more frequently in winter, smoking is a significant risk factor for CAP.

"Typical" CAP

• Typically, those with typical CAP exhibit a sudden onset of fever, shortness of breath, and classic symptoms/signs in a previously healthy individual.
• The causative agents are usually culturable and susceptible to cell-wall-active antibiotics.
• Notable physical examination findings include tachycardia, tachypnea, productive cough with purulent sputum and possible hemoptysis, pallor, and cyanosis.
• CXR demonstrates lobar consolidation.
• CBC displays leukocytosis (increased white blood cells), with a 'left shift' indicative of infection.
• Sputum sampling often reveals neutrophils and RBCs; Gram stain may identify the causative agent.

"Atypical" CAP

• Atypical CAP onset of symptoms is typically delayed and mild.
• Fever, sore throat, and a persistent cough are frequent symptoms; minimal sputum is produced.
• Patients who present with typical signs of a cold or the flu are often able to continue working/daily activities. The infection shows lower spread rates through the public. Patients may not show classic signs of illness but still require treatment.
• Physical exam commonly reveals a mildly ill-appearing patient with diffuse wheezing; causative pathogens are frequently hard to culture using standard diagnostic methods.
• Atypical CAP generally doesn't respond to penicillins.

Mycoplasma Pneumonia

• Caused by Mycoplasma pneumoniae.
• Characterized by mild symptoms of cold/flu.
• Often doesn't necessitate hospitalization.

Chlamydophila Pneumonia

• Caused by Chlamydophila pneumoniae bacteria.
• School-aged children are more prone to infection.
• Legionnaires' disease (more serious) is also caused by Legionella pneumophilia bacteria.
• Not spread through person-to-person contact

Common Causes of CAP Requiring Hospitalization

• Previously healthy individuals may be affected by Streptococcus pneumoniae or Staphylococcus aureus.
• Underlying conditions such as chronic bronchitis, other lung infections or pre-existing conditions (e.g., AIDS, influenza, tuberculosis, or other gram-negative rods) may exacerbate pneumonia risk. Infections from viruses or atypical bacteria may also increase vulnerability.

Most Common Causes for Viral Pneumonia

• Influenza, parainfluenza, adenovirus, RSV, and cytomegalovirus are common.

Features of Severe Pneumonia

• Common symptoms or signs that classify pneumonia as severe include confusion, urea greater than 7 mM, breathing rate exceeding 30 per minute, blood pressure below 90 mmHg systolic or below 60 mmHg diastolic.

Hospital-acquired Pneumonia (HAP)

• Acute lower respiratory tract infection (LRTI) that develops at least 48 hours after hospital admission, and absent at admission. • Also known as nosocomial pneumonia.
• Conditions like ventilator-associated pneumonia (VAP). • Develops at least 48 hours after endotracheal intubation. • Factors increasing risk for pneumonia, include decreased cough/epiglottal reflex or function, impaired mucociliary mechanisms, pollution, cigarette smoking, upper respiratory infections, tracheal intubation, factors related to aging and metabolic disorders. Common organisms associated with hospital-acquired pneumonia (HAP) include Enterobacteriaceae, Escherichia coli, Haemophilus influenzae, Klebsiella species, Proteus, Serratia marcescens, Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus (MRSA), and Streptococcus pneumoniae.

Pneumonia in Immunocompromised Hosts

• Immunocompromised hosts are more prone to pneumonia development.
• Pneumocystis pneumonia (PCP), fungal infections, and Mycobacterium tuberculosis are common causative factors.
• Conditions such as aspiration pneumonia are likely to be caused by endogenous or exogenous substances.

Clinical Manifestations of Pneumonia

• Frequent coughing that produces greenish/yellow sputum.
• High fever commonly accompanied by chills.
• Shortness of breath.
• Tachypnea (rapid breathing).
• Pleuritic chest pain.
• Headache
• Associated symptoms can include Sweaty and clammy skin, loss of appetite, fatigue, blueness of the skin, nausea, vomiting, mood swings, and joint pains/muscle aches.

Diagnostic Procedures for Pneumonia

• Patient history collecting to gather relevant information, including the illness history and smoking status.
• Physical examination assessing symptoms
• Radiographic procedures (chest X-ray) to investigate lung abnormalities.
• Gram stain and culture of sputum to identify pathogens.
• Complete blood count (CBC) to determine white blood cell counts.
• Blood oxygen saturation monitoring (pulse oximetry)
• ABGs to determine oxygen and carbon dioxide levels.
• Other procedures such as blood and sputum cultures, and invasive procedures (e.g. transtracheal aspiration, bronchoscopy, and lung aspirations）are used.

Medical Management of Pneumonia

• Drug treatment protocols vary according to severity and patient factors. Ambulatory treatments for mild pneumonia might use amoxicillin, erythromycin, or doxycycline. For hospitalized patients suffering from severe pneumonia, benzyl penicillin and gentamicin (or ceftriaxone) may be administered.
• Drug treatment protocols involving staphylococcus aureus include cloxacillin, usually administered intravenously or intramuscularly.
• For community-acquired hospitalized patients with severe pneumonia, supportive measures will be necessary and often include bed rest, temperature/blood pressure/pulse monitoring, fluid replacement, oxygen administration, and pain relief as necessary.

Chronic Obstructive Pulmonary Disease (COPD)

• COPD is a chronic irreversible airflow limitation.
• It encompasses chronic bronchitis and emphysema, a combination of respiratory conditions.
• COPD results from narrowing of the airways, causing breathing difficulties.

Causes of COPD

• Major causes of COPD include smoking, occupational exposures, air pollution, and bronchial hyperresponsiveness. Genetics, in the form of alpha-1 antitrypsin deficiency, also contributes.
• Sudden constriction of airways in response to inhaled irritants is a critical factor in the etiology.

Pathophysiology of COPD

• COPD involves an inflammatory response to toxic gases that affects the airways, parenchyma, and pulmonary vasculature and results in airway narrowing.
• Destruction of lung tissue (parenchyma) leads to emphysema.
• Imbalances in proteinases and antiproteinases (enzymes associated with tissues breakdown) can cause structural damage.
• Mucus hypersecretion and cilia dysfunction also characterize this disease, leading to increased airflow resistance and breathing effort.

Clinical Features of COPD

• Clinical features of COPD often include chronic cough, sputum production, wheezing, shortness of breath during exertion, weight loss, respiratory insufficiency, and respiratory infections.
• Chronic hyperinflation results in barrel-shaped chest distortion from increased lung volume.

COPD Diagnosis

• Spirometry testing with airflow obstruction measurements is crucial for diagnosing COPD.
• A post-bronchodilator FEV₁/FVC ratio below 0.70 suggests persistent airflow limitation.
• The Modified British Medical Research Council (mMRC) scale is used to evaluate breathlessness severity.

COPD Treatment

• Managing COPD requires addressing the underlying causes, as there is no cure.
• Drug therapies involve bronchodilators (beta2-agonists, anticholinergics, and methylxanthines) and corticosteroids.
• Surgical management includes bullectomy (for removal of enlarged air spaces) and lung volume reduction surgery (for removal of diseased section of the lung) lung transplantation.
• Pulmonary rehabilitation, patient education, breathing exercises, activity pacing, self-care strategies, and nutritional therapy also contribute to management.

Nursing Management of COPD

• Patient assessment regarding respiratory status, airway clearance, breathing patterns, and tolerance of activity should be performed for each COPD patient.
• Complications, like respiratory insufficiency and failure, must be monitored.

Emphysema

• Emphysema is characterized by an abnormal distention of the airspaces distal to the terminal bronchioles. A significant aspect is the destruction of the bronchiole walls associated with increased air space and reduced capacity.
• Key aspects include the loss of elasticity in airways/air sacs, destruction of walls between air sacs, thickened/inflamed airway walls, and increased mucus production, all leading to air blockage within the lungs.

Emphysema Types

• Centrilobular emphysema (CLE): The proximal and central portion of the acinus displays expansion, but the peripheral areas are unaffected. It commonly correlates with smoking; often observed in coal miners/smokers with a similar respiratory issue called 'pneumoconiosis.
• Panacinar emphysema often occurs due to alpha-1 antitrypsin deficiency, and significantly affects the entire acinus (including the respiratory bronchioles and alveoli), predominantly found in lower lobe basal segments and anterior margins of the lung.
• Paraseptal emphysema: Often occurs with other conditions (most notably spontaneous pneumothorax). It does not necessarily impact the entire acinus but can be associated with damage adjacent to the regions.

Clinical Manifestations of Emphysema

• Early stages may exhibit wheezing, chronic fatigue, and difficulty sleeping/resting due to lung abnormalities. Physical signs like barrel chest, central cyanosis, finger clubbing, dyspnea(difficulty breathing), and possible coughing/sputum production should also be monitored.
• Later signs include hypercapnea (CO2 buildup), labored/pursed lip breathing, increased use of accessory muscles for breathing, and often, weight loss/inability to maintain appetite.

Diagnosis of Emphysema

• Collection of a medical history from the patient that includes smoking/occupational history is necessary.
• A physical examination is required to evaluate the physical signs noted earlier in clinical presentations
• PFT, including spirometry, will aid investigation into airflow obstruction related to COPD.
• ABG analysis and CXR and CBC are common diagnostic procedures.
• Lung scans and alpha-1-antitrypsin deficiency screenings are employed.

Treatment of Emphysema

• The treatment for emphysema often emphasizes risk reduction, specifically preventing exposure to respiratory irritants, and stopping smoking.
• Pharmacologic therapies may include bronchodilators (beta-2 agonists, anticholinergics, methylxanthines), corticosteroids, and other related medications for symptom management.
• Surgical management may encompass bullectomy, lung volume reduction surgery, and potentially lung transplantation in relevant cases.
• Nursing interventions, including patient education, breathing techniques, and activity pacing, are also crucial.

Asthma

• Asthma is a chronic inflammatory disorder of the airways characterized by recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, mainly at night or early morning.

Asthma Classifcation

• Asthma can be categorized as atopic (extrinsic) or non-atopic (intrinsic) depending on whether the underlying cause of the disease is mediated through antibodies (e.g., IgE) or not.
• Atopic: increased plasma IgE levels in response to environmental antigens; typically has a childhood onset.
• Non-atopic: sensitivity of airways to nonimmune stimuli, without noticeable IgE elevation; can be triggered by inhaled irritants, exercise, stress, or certain substances.

Asthma Pathophysiology

• Chronic inflammation of the airways is a significant hallmark of asthma.
• Airway hyperresponsiveness is also critical, whereby the airways become narrowed after exposure to an allergen/irritant.
• Edema of mucosal cells is common along with increased mucus overproduction.

Etiology of Asthma

• Allergy is the primary causative factor.
• Common allergens include seasonal allergens (e.g. grass, tree, and weed pollens) or perennial allergens (e.g., mold, dust, roaches, or animal dander).
• Other asthma triggers include respiratory irritants (e.g., air pollutants, cold/heat changes, fumes, smoke), exercise, stress, emotional upset, certain medications, viral respiratory infections and acid reflux.

Clinical Manifestations of Asthma

• The three most frequent symptoms are cough, respiratory discomfort (dyspnea), and wheezing.
• The exacerbation progresses, potential signs can be diaphoresis (increased sweating), tachycardia (increased heart rate), symptoms of hypoxemia (including low blood oxygen and possible cyanosis).

Status Asthmaticus Stages

• Status asthmaticus (prolonged severe asthma exacerbation) categorizations include three stages: refractory response to bronchodilators, severe airway obstruction with bronchospasm and atelectasis (silent chest), and hypercapnic coma (marked CO₂ buildup).

Asthma Assessment & Diagnostic Findings

• Patient history (

Test your knowledge on the primary immune mechanisms associated with extrinsic asthma, common triggers, and the pathophysiology of asthma. This quiz covers key concepts associated with asthma, including atopic and non-atopic forms, and the various factors influencing asthma symptoms and triggers.