Chronic Respiratory Disorders: Nursing Management

Class Objectives

• Safe and effective nursing management of pharmacotherapeutic regimes for individuals across the lifespan and their families experiencing chronic respiratory disorders should be identified.
• Nursing outcomes and interventions (therapeutics) for individuals and their families should be identified.
• Nursing diagnoses, outcomes, and interventions should be prioritized to create a nursing care plan for a case study.
• Collaborative approaches should be built to support self-management and effective coping for individuals across the lifespan and their families experiencing chronic disorders of the respiratory system.
• The topics covered include: Bronchopulmonary Dysplasia, Cystic Fibrosis, End-stage COPD, Interstitial Lung Disease, and Pulmonary Artery Hypertension.

Bronchopulmonary Dysplasia (BPD)

• BPD is a chronic lung disease that develops in preterm neonates who have been treated with oxygen and positive-pressure ventilation.
• Those who have had BPD are prone to lung infections and chronic lung issues in the future.
• Treatments include antibiotics, corticosteroids, diuretics, electrolyte replacement, and bronchodilators.

Surfactant Therapy

• Surfactant therapy is used in the prevention and treatment of BPD.
• Surfactant is a lipoprotein that lowers the surface tension in the alveoli.
• It is instilled via an endotracheal tube in liquid form.

Other Therapeutic Interventions for BPD

• Neonates require high calories for growth and healing, with total energy requirements of >130 kcal/kg/day and protein intake of 3.5-4 g/kg/day.
• Modest fluid restriction may be prescribed with high caloric density feedings.
• Avoid high (>95%) and low oxygenation, targeting Sp02 between 90-95%.
• Infants with BPD may experience sudden episodes of pulmonary decompensation, which can be identified by worsening gas exchange and respiratory distress caused by bronchospasm, fluid retention in the lungs, pulmonary air leak, endotracheal tube displacement, or symptomatic tracheobronchomalacia.

Cystic Fibrosis

• Early interventions for growth and development in infants with cystic fibrosis involve targeted nutrition leading to increased height and weight.
• Goals of interventions include minimizing pulmonary complications, ensuring adequate nutrition for growth (height, weight, bone density), promoting appropriate physical activity, and ensuring a reasonable quality of life for the child and family.

CF Therapeutic Pharmacological Interventions

• CFTR modulator therapy
• Airway Clearance Therapies (hypertonic saline DNase)
• Intermittent antibiotic therapy as needed, as colonization of MRSA is a critical factor, potentially requiring longer hospital stays
• Glucocorticoid therapy as needed

CF Therapeutic Interventions for Pulmonary Issues

• Antibiotic therapy
• Airway Clearance Therapies (hypertonic saline DNase)
• Oxygen as needed
• Chest physiotherapy
• Viscous secretions are a growing medium for bacteria.

Cystic Fibrosis Non-Pharmaceutical Interventions

• Chest physiotherapy is essential for illness prevention and treatment.
• Chest physio typically occurs twice daily and includes percussion and postural drainage, positive expiratory pressure (PEEP), active cycle-of-breathing, autogenic drainage, oscillatory PEP devices, high-frequency chest compression (HFCC), exercise, and percussive vests.

Cystic Fibrosis Developmental Considerations

• Living with cystic fibrosis can be stressful and children may need gentle coaxing, positive reinforcement, and frank negotiation.
• Families may need emotional support/validation and local, national, and international support groups offering emotional and practical support.

Invasive Lines and CF

• Invasive lines can be stressful and include peripherally inserted vascular access devices, centrally inserted vascular access devices (CVADs) for medications, fluids, and nutrition (TPN), feeding tubes (NG, NG, G-Tube), and oxygen and nebulizer equipment.

CF Gastrointestinal and Endocrine Interventions

• Energy requirements are typically at least 150% of recommended daily allowances.
• Replacement of pancreatic enzymes is needed; goal of max of 1-2 stools/day.
• Prolapse of the rectum is associated with large, bulky stools, with risk of bowel obstruction.
• The most common complication in children is cystic fibrosis-related diabetes (DFRD).
• Insulin is the recommended treatment for DFRD, and oral hypoglycemics are not effective, ketoacidosis is rare. By age 30, 50% of CF patients have diabetes.
• A high-fat, high-calorie diet is still recommended.

Discussions around sexuality

• Includes fertility issues, as 95% of males have congenital absence of vas deferens but are not impotent.
• Assisted reproductive technology is usually required for males.
• Females with CF are less fertile due to having highly viscous cervical secretions and lower conception rates.
• Genetic counselling is highly advised, with females having a higher incidence of low-birth-weight babies and spontaneous abortions.
• Clinical manifestations include dyspnea, cough (with or without sputum), sputum production, wheezing/prolonged expiration, and hypoxia.

COPD Complications

• An exacerbation is an event marked by the worsening of dyspnea and/or cough and sputum production for a period of up to 14 days, accompanied by tachypnea and/or tachycardia, often caused by airway infection, pollution, or other irritants.
• Cough becomes more frequent and severe, sputum production increases in volume and/or changes in appearance, and dyspnea becomes more intense.

COPD Complications

• Hospitalization
• Hypercapnia
• Hypoxia, possibly causing Secondary polycythemia
• Exacerbation +/- Respiratory Failure
• Excessive sputum/mucous production, contributing to risk for pneumonia
• General weakness affecting the ability to cough effectively and to expel air from lungs effectively during regular respirations (air trapping disease)
• Chronic anemia, fatigue, malnutrition/cachexia/sarcopenia, skeletal muscle dysfunction (wasting), pulmonary hypertension, right heart failure (Cor Pulmonale), anxiety/panic attacks, and depression.

COPD Pharmacological Interventions

• Inhaled Bronchodilators
• Short Acting: SABAS (short-acting beta-agonist): i.e., Ventolin
• SAMAS (short-acting muscarinic antagonists): i.e., Ipratropium
• Long Acting: LABA (long-acting beta2 agonist), i.e., salmeterol
• LAMA (long-acting muscarinic agonists), i.e.. tiotropium
• +/- Inhaled Glucocorticoids +/-
• Oral/intravenous glucocorticoids (prednisone/methylprednisolone)

COPD Gas Exchange

• Oxygen is a medication and the drive to breathe is based on arterial C02.
• Therapy aims to titrate the flow rate to achieve Sa02 between 88% and 92%.
• Avoid administering 02 per facial mask at rates of <=6 as this lack of flow will prevent proper clearance of CO2 through the vents in the mask, and thus, causing hypercapnia.
• Be cautious when administering nebs via masks.
• Remember to remove the mask when nebulizer is completed as it is connected to 02.
• Assessment for CO2 toxicity should be factored into all monitoring priorities.
• It is important to be mindful of situations where CO2 retention can be potentiated, for example, narcotics.
• Oxygen supports combustion; smoking with 02 is dangerous.

Nurses role in COPD

• Nurses should promote and encourage purse-lipped breathing and tripoding for dyspnea as well as Huff Cough exercise

Bilevel Positive Airway Pressure (BIPAP)

• Bilevel positive airway pressure (BPAP) is used during non-invasive positive pressure ventilation (NPPV).
• It delivers a pre-set inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure (EPAP), correlating tidal volume with the difference between the two.
• Positive air pressure is applied on inspiration and expiration, with higher pressure on inspiration, and the mask must have secure seal.

Continuous Positive Airway Pressure (CPAP)

• CPAP is NOT the same as BIPAP.
• CPAP aims to apply the minimal pressure to resolve apneas, snoring, and obstructive events in the upper airway.
• There is only sufficient airway pressure applied to open the airways; it is not for treating hypercapnia.

COPD Education

• Smoking cessation, avoidance of irritants, and education on medications equips patients to support symptom relief and slow disease progression
• Self-care strategies which maintain activity to prevent deconditioning and build resilience
• Supplemental oxygen and C02 Education, and Portable Sa02 oximeters can be purchased It is important to know which concerns should be communicated to the healthcare team and for early vaccination
• Energy requirements (1.2-1.3x the normal kcal) and avoid foods that cause discomfort

COPD Preservation of Energy

• Meal prep should be avoided . immediately prior
• Using SABA (Ventolin) may assist with dyspnea
• Sleep or frequent naps can promote rest
• Relaxation techniques help with stress, such as with depression or with anxiety

COPD Surgical Interventions

• Lung volume reduction surgery and lung transplantation.

COPD Palliative Care

• Support open communication relating to patient concerns

Interstitial Lung Disease -Manifestations & Interventions

• Clinical manifestations include progressive dyspnea with exertion, persistent non-productive cough. The disease is progressive.
• Interventions include supplemental oxygen, pulmonary rehab, prevention of infections and acute exacerbations with vaccine
• Eat small meals of protein

Interstitial Lung Disease - Pharmacology

• Antifibrotic that affects fibrotic pathways

Pulmonary Hypertension

• Obstructive/restrictive may be cause with hypoxia
• Pulmonary Hypertension interventions including exercise where indicated

Cor Pulmonale (Right Heart Failure)

• Hypertrophy of the Right side of heart as a result from End result of pulmonary HTN

lung Transplant care

• Patient must be be healthy enough and take medicine for life to prevent rejection

Respiratory Interventions

• Humidified High Flow Nasal Cannula and Tracheotomy may be options

Respiratory Interventions - Tracheotomy

• Incision may be created and an airway put in place allowing the patient to have a longer term route to have air intake

Tracheostomy

• Safety includes keep extra kit, cuff up may make a tighter to hole, cuff pressure should remain in certain levels, may be accidental removal if not careful

IF Fenestrated Trach cannula:

Patient must be able to cough, allow them breathing techniques

Tracheostomy Decannulation

• Techniques help

1. Plug or cork the trach
2. exchange air and remove

Respiratory Interventions - Accidental Tracheostomy Decannulation

• DO NOT ATTEMPT TO RE-INSERT

1. Assess the patient
2. Apply needed

Long COVID

• Vaccination has helped and may need in patient rehab.

Long COVID - interventions

• Specialty is key for PTST and consult as needed.

Explore nursing management of chronic respiratory disorders like Bronchopulmonary Dysplasia and Cystic Fibrosis. Learn to identify nursing outcomes, prioritize diagnoses, and build collaborative approaches for effective self-management. Understand pharmacotherapeutic regimes for individuals and families across the lifespan.