Exam 20 - Lower Airway Disorders

Acute Bronchitis

• Typically originates secondary to an Upper Respiratory Infection (URI)
• Inhaled irritants can be a contributing factor
• It causes inflammation of the mucous membranes of major bronchi and their branches
• Can result in tenacious secretions conducive to bacterial growth

Clinical Manifestations of Acute Bronchitis

• Includes a productive cough
• Patient has a low-grade fever
• Diffuse rhonchi and wheezes are present
• Dyspnea and chest pain are reported
• Generalized malaise and headache

Assessment of Acute Bronchitis

• Subjective symptoms include headache, body aches, and chest tightness
• Frequent vital sign assessment required
• Auscultate breath sounds, identifying rhonchi, wheezing, or basilar crackles

Diagnostics of Acute Bronchitis

• Chest x-rays are needed to view the lung fields
• Sputum cultures help determine bacterial infection

Medical Management of Acute Bronchitis

• Focuses on quick recovery and prevents secondary infection
• Bronchodilators (e.g., albuterol) are used
• Antibiotics treat active infection or prophylaxis (e.g., ampicillin)
• Cough suppressants of opioid (codeine) or non-opioid (dextromethorphan) forms can be used
• Antipyretics (e.g., Tylenol) are used for fever

Nursing Interventions for Acute Bronchitis

• Focuses on facilitating recovery and preventing secondary infections
• Assess for infection signs and symptoms like fever, dyspnea, and mucopurulent sputum
• Administer prescribed antipyretics and antibiotics
• Monitor the patient’s ability to move secretions, noting any increase in retained secretions
• Facilitate airway clearance by elevating the head of the bed and liquefying secretions with a humidifier
• Adequate fluid intake (3000-4000 mL/day) is key
• Suction as needed if patient cannot clear secretions themself
• Avoid offering dairy products when administering fluids

Patient Teaching for Acute Bronchitis

• Prevent exacerbations or recurrence of infections
• Increase fluid intake is important
• Incorporate rest periods whenever possible
• Recognize worsening symptoms like purulent sputum, dyspnea
• Use analgesics and antipyretics for symptom relief
• Avoid irritants

Prognosis for Acute Bronchitis

• Is generally "Good"

Legionnaires' Disease

• The Etiology or Pathophysiology is caused by Legionella pneumophila
• Legionella pneumophila is a gram-negative aerobic bacillus that thrives in water reservoirs
• Spread through the airborne route
• It presents in two forms: influenza or Legionnaire's disease
• Causes life-threatening pneumonia with lung consolidation and alveolar necrosis
• Can progress rapidly (less than a week) to respiratory and renal failure, bacteremia shock, and death

Clinical Manifestations of Legionnaires' Disease

• Significantly elevated temperature
• Headache
• Nonproductive cough
• Diarrhea
• General malaise

Assessment for Legionnaires' Disease

• Subjective: Note complaints of dyspnea, headache, and chest pain on inspiration
• Objective:
  • Significantly elevated temperature (102-105°F or 38.8-40.5°C)
  • Non-productive cough with difficult and rapid breathing
  • Crackles and wheezing on auscultation
  • Signs of shock (tachycardia and hypotension)
  • Hematuria indicating renal impairment

Diagnostics for Legionnaires' Disease

• Urine testing to confirm diagnosis
• Cultures of blood, sputum, and pulmonary tissue/fluid to confirm presence of L. Pneumophila
• Chest x-ray: patchy infiltrates and small pleural effusions

Medical Management for Legionnaires' Disease

• Close observation for disease progression
• Possible mechanical ventilation for respiratory support
• Temporary renal dialysis due to acute kidney failure
• IV therapy for fluid and electrolyte replacement
• Oxygen therapy

Medications for Legionnaires' Disease

• Antibiotics (e.g., erythromycin IV early, then oral)
• Rifampin
• Antipyretics for hyperthermia
• Vasopressors (dopamine or dobutamine) and/or inotropes (for cardiac output and shock)
• Analgesics to promote comfort

Nursing Interventions:

• Maintain bed rest and monitor I&Os (Input & Output)
• Monitor for impending shock: decreased blood pressure and increased pulse
• Administer vasopressor drugs as ordered
• Maintain hydration status and urinary output
• Assess changes in level of consciousness
• Assist with acute hemodialysis if indicated
• Assess for respiratory failure
• Note respiratory rate, rhythm, and effort
• Be alert for cyanosis and dyspnea
• Assist with oxygen therapy or mechanical ventilation
• Facilitate ventilation; semi-Fowler's position if tolerated and suction as needed
• Have patient cough and deep breathe q 2 hr if able
• Identify associated factors, such as ineffective airway clearance, pain, and altered level of consciousness

Severe Acute Respiratory Syndrome (SARS)

• The Etiology and Pathology is an infection caused by a coronavirus
• Spreads through close contact (likely via respiratory droplets) and possibly by touching contaminated objects

Clinical Manifestations of SARS

• Fever greater than 100.4°F (38°C)
• Headache
• Discomfort and muscle aches
• Dry cough and shortness of breath (after 2-7 days)

Diagnostic Tests for SARS

• Chest radiograph
• Nasopharyngeal and oropharyngeal swabs
• Bronchoalveolar lavage

Medical Management of SARS

• Respiratory isolation, including use of a particulate respirator mask
• Antiviral medications (e.g., ribavirin) and corticosteroids may be given
• Antibiotics are not effective against the virus but may be used for secondary bacterial infections

Nursing Interventions for SARS

• Notify local public health department when a patient contracts it
• Implement respiratory isolation and meticulous hand hygiene to prevent spread
• Discharge home when respiratory status returns to baseline (10 days after fever resolves and symptoms improve)

Anthrax

• Etiology/Pathophysiology is caused by Bacillus anthracis (gram-positive aerobe)
• Most commonly infects hoofed animals
• Spread through direct contact with bacteria and spores, dormant spores become active in a living host
• Spores enter via skin, intestines, or lungs
• Not normally person-to-person, but contact with infected tissue is contagious

Three types of Anthrax

• Cutaneous: most common; enters through skin cut or abrasion, forming a black eschar. Typically not fatal with antibiotics
• Gastrointestinal: least common; from ingesting contaminated food, causing ulcers. Can cause death from sepsis if not treated early
• Inhalation: most deadly; spores inhaled into lungs

Clinical Manifestations of Inhalational Anthrax

• Initial symptoms like a cold or influenza, but without nasal secretions
• Subsequent breathing problems, hemorrhage, tissue necrosis, and lymph edema
• Death usually from blood loss and shock

Diagnostic Tests for Anthrax

• Chest x-ray to differentiate from pneumonia (widened mediastinum is characteristic of inhalational anthrax)
• Culture specimen from vesicular fluid for cutaneous anthrax
• Stool specimen for culture if intestinal anthrax is suspected

Medical Management of Anthrax

• Antibiotic therapy for all cases
• Ciprofloxacin (Cipro) treatment of choice due to possible resistance to other antibiotics
• The recommended regimen is a 60-day course of therapy
• Alternative therapy of 30 days of antibiotics and 3 doses of anthrax vaccine

Tuberculosis (TB)

• Etiology/Pathophysiology is a chronic pulmonary and extrapulmonary infectious disease
• Acquired by inhaling a dried droplet nucleus containing Mycobacterium tuberculosis
• Most commonly affects the lungs, but can affect other areas
• Macrophages ingest TB bacteria, which form hard capsules called tubercles and TB can remain dormant for many years

Infection vs Active TB Disease

• Infection precedes active disease; only 10% of infections progress
• Infection if presence of mycobacteria, no symptoms, demonstrates antibodies (+PPD), negative chest x-ray (latent TB)
• Disease is determined by pathologic signs and symptoms indicating mycobacteria activitiy with a positive skin test, positive chest x-ray, positive sputum or gastric contents for AFB

Predisposing Factors for TB

• Include a compromised immune system, close contact, low-income populations, health care workers
• Also factors include those born in high prevalence countries, residents of long term care, and the elderly

Clinical Manifestations of TB

• May have no symptoms, or they may develop insidiously
• Early symptoms: anorexia/weight loss, productive cough, fever, weakness
• Later symptoms: recurring fever with chills, night sweats, hemoptysis

Assessment of TB

• Subjective: note reports of loss of muscle strength and weight loss
• Objective: evaluate and report characteristics of sputum (amount, color, blood)

Diagnostic Tests for TB

• Mantoux tuberculin skin test (PPD): read 48-72 hours later, measure induration

  • Negative reaction: less than 5mm
  • A positive TB test indicates antibodies are present, not necessarily active TB

• Sputum culture for acid-fast bacillus (AFB) to confirm active TB

  • Three positive acid-fast smears indicate a presumptive diagnosis
  • Diagnosis is confirmed with tubercle bacilli growth in culture (6-8 weeks)

• QuantiFeron-TB Gold Test: more specific than PPD with results 24 hours after collection

• All patients with TB must be reported to public health authority

Medical Management of TB

• Isolation: AFB isolation during hospital stay
  • Negative pressure ventilation room, particulate matter mask
  • Patients wear a mask when leaving room
  • Infants/children do not generally require isolation
• Medications: drug therapy for active TB
  • Treatment is lengthy (6-9 months or longer), combination of medications
  • Common medications include isoniazid, rifampin, pyrazinamide, streptomycin or ethambutol
  • Pyrazinamide is associated with uric acid elevations

Nursing Interventions for TB

• Implement isolation measures for suspected TB
  • Negative pressure room
  • Patients cover their nose and mouth when coughing or sneezing
• Focus on preventing complications and illness transmission
• Monitor for dyspnea or signs and symptoms of pneumothorax
• Evaluate respiratory effort and assist as needed
• Assess sputum for hemoptysis
• Help immobile patients to turn, cough, and deep breathe q 2–4 hr to prevent pooling of secretions
• Obtain specimen for culture (proper collection and handling)
• Employ AFB isolation until therapy is initiated successfully
• Employ drainage and secretion precautions until wounds from patient with extrapulmonary TB stop draining
• Instruct patient to cough and sneeze into tissue and properly dispose of it

Pneumonia

• Etiology/Pathophysiology is an inflammatory process of respiratory bronchioles and alveolar spaces, the cause is infection, irritation, aspiration, over-sedation, and inadequate ventilation
• Can occur any season but most common during winter and spring
• More common in infants and older adults
• Susceptible patients: damaged respiratory defense mechanisms, diseases affecting antibody response, alcoholics, delayed WBC reaction
• Mode of transmission depends on the infecting organism

Classification of Pneumonia

• Bacterial pneumonia: alveolar pus formation with consolidation (Streptococcus pneumoniae, Hemolytic strep type A, Staphylococcus aureus, Haemophilus influenza type B, and Legionella pneumophila are listed)
• Nonbacterial or atypical: Mycoplasma, Legionella pneumophila, Pneumocystis jiroveci
• Aspiration pneumonia: foreign or toxic material, (Staphylococcus aureus, Escherichia coli, Klebsiella, Pseudomonas, and Proteus species are listed as causes), often during altered LOC
• Viral pneumonia: interstitial inflammation without consolidation or exudates (mycoplasma included here)
• Fungal/mycobacterial pneumonia: patchy distribution with necrosis and cavities, including Chemical causes dependent on pH

Clinical Manifestations of Pneumonia

• Sudden onset of sharp chest pain (pleurisy)
• Severe chills
• Elevated temperature and night sweats
• Painful, productive cough (often purulent)
  • Streptococcal/pneumococcal will present a rust color
  • Staphylococcal will present a salmon color
  • Haemophilus will present a yellow/green color
  • Viral will present a mucopurulent or blood-tinged color
• Increased heart rate
• Tachypnea with dyspneic expiration

Assessment of Pneumonia

• Patient history and physical exam
• Subjective: Description of onset, duration, and history of cough, fever, and night sweats
• Objective:
  • Level of consciousness
  • Vital signs are needed every two hours (especially temperature and respirations)
  • Monitor color, consistency, and amount of sputum
  • Observe respiratory effort and difficulty with breathing
• Auscultate for inspiratory crackles or localized absent breath sounds

Diagnostic Tests for Pneumonia

• Blood and sputum cultures to identify organism (sputum culture before antibiotics)
• Chest x-ray reveals changes in density (lower lobes)
• WBC elevated in bacterial, decreased in viral/mycoplasma
• Pulmonary function test to determine if lung volume is decreased
• ABG to identify altered gas exchange
• Oximetry for rapid and continuous oxygen assessment

Medical Management of Pneumonia

• Medications:
  • Antibiotic therapy like penicillin, erythromycin, cephalosporin, and tetracycline
  • Antibiotics are not effective in viral pneumonias
  • Oxygen therapy
  • Analgesics/antipyretics
  • Expectorants
  • Bronchodilators
• Vaccine available for streptococcal pneumonia
• Indicated for those with chronic illness, recovering from serious illness, older than 65, or in long-term care facilities
• Physiotherapy: chest percussion and postural drainage, encourage cough, deep breathing, incentive spirometry, and ambulation to mobilize secretions
• Humidification with humidifier or nebulizer for tenacious secretions
• Chest tube for pus in pleural space (empyema)

Nursing Interventions for Pneumonia

• Assess ventilation: rate, rhythm, depth; chest expansion; and respiratory distress
• Auscultate lungs for crackles, wheezes, and pleural friction rub
• Identify contributing factors such as airway clearance or obstruction problems or weakness
• Encourage increased fluid intake to 3 L/day to liquefy secretions
• Maintain patient in semi-Fowler's or sitting and leaning forward
• Assess for signs of hypoxemia (restlessness, disorientation, and irritability)
• Administer oxygen to maintain saturations above 90%
• Monitor body temperature
• Provide hydration to liquefy secretions and replace fluids. Fluid intake of at least 3 L/day, individualized for patients with heart failure with an intake of at least 1500 calories/day

Patient Teaching for Pneumonia

• Deep-breathing and coughing techniques and the use of an incentive spirometer
• Hand washing to prevent spreading
• Prescribed medications (purpose, action, dosage, frequency, side effects)
• Specific type of pneumonia, treatment, anticipated response, and complications
• Understand that large quantities of fluid need to be consumed unless those patients have pulmonary edema, congestive heart failure, and/or renal failure
• Adaptive exercise and rest techniques will help their body recover
• Availability of pneumococcal vaccine
• Report changes in sputum, decreased activity tolerance, fever despite antibiotics, increasing chest pain, or a feeling that things are not getting better

Prognosis for Pneumonia

• Usually improves in 2-3 days and resolves within 2-3 weeks with proper treatment
• Major cause of disease and death in critically ill patients
• Pneumonia and influenza remain a leading cause of death in the US
• Bacterial aspiration pneumonia carries a poor prognosis

Pleurisy

• Etiology/Pathophysiology is an inflammation of the visceral and parietal pleura
• Causes: bacterial or viral infection, spontaneous, complication of pneumonia, TB, pleural trauma, pulmonary infarction, lung cancer, viral infections of intercostal muscles

Clinical Manifestations of Pleurisy

• Sharp inspiratory pain, radiating to shoulder or abdomen of the affected side
• Fever and dry cough if pleural effusion develops (pain will diminish)
• Dyspnea
• Elevated temperature

Assessment of Pleurisy

• Subjective: patient complaint of chest pain on inspiration, elevated temperature
• Objective:
  • Assess the nature of inspiratory pain, including radiation
  • Frequent vital signs, including temperature
  • Respiratory rate and rhythm, noting dyspnea
  • Auscultate for pleural friction rub

Diagnostic Tests for Pleurisy

• Pleural friction rub may be considered diagnostic
• Chest x-ray of limited value unless pleural effusion is present

Medical Management of Pleurisy

• Medications:
  • Analgesics (Demerol or morphine) and antipyretics (Tylenol)
  • Antibiotics for the underlying cause (e.g., penicillin)
  • Oxygen therapy for inadequate gas exchange
  • Anesthetic block of intercostal nerves

Nursing Interventions of Pleurisy

• Assess for pain
• Administer medications as ordered and assess effectiveness
• Provide non-pharmacologic comfort measures
• Encourage lying on the affected side to splint the chest wall
• Position the patient comfortably on the affected side and apply heat to the area
• Assess LOC, noting any increase in restlessness or disorientation
• Auscultate lungs for wheezes, crackles, and pleural friction rub
• Teach patient to cough and deep breathe every 2 hours and to splint rib cage when coughing
• Heat may be applied to the affected side
• Elevate head of bed
• Reposition patient every two hours

Pleural Effusion or empyema

• Etiology/Pathophysiology is a fluid accumulation in the pleural space, may or may not be infected
• Rarely primary, occurs when the physiologic pressure in the lungs and pleurae is disturbed (Pancreatitis, cirrhosis of the liver and heart failure are common causes)
• When the fluid is infected, it gets called empyema (Usually bacterial associated with pneumonia, TB and blunt chest trauma like a car crash etc)
  • May be acute or chronic, but if untreated the pleura may become scarred and fibrosed

Clinical Manifestations of Pleural Effusion

• Generally associated with other disease processes
• Persistent fever despite antibiotics

Assessment of Pleural Effusion

• Subjective: Assess dyspnea, air hunger, fear, and anxiety related to decreased oxygen level
• Objective:
  • Signs and symptoms of respiratory distress (nasal flaring, tachypnea, dyspnea)
  • Decreased breath sounds, dry cough
  • Frequent vital signs, especially temperature

Diagnostic Tests for Pleural Effusion

• CXR to visualize effusions
• Thoracentesis to obtain specimen for culture and for symptomatic treatment of dyspnea

Medical Management of Pleural Effusion

• Thoracentesis to remove fluid from the pleural space (less than 1300-1500 mL at a time)
• Chest tube placement for continuous drainage
• Re-establishes negative pressure in the pleural cavity

Chest Tube Management

• Chest Tubes and Drainage System are inserted for continuous drainage of fluid, blood, or air from the pleural cavity, and for medication instillation
• Sutured in place and covered with a sterile dressing
• Closed drainage system maintains negative pressure
• Intrapleural pressure is below atmospheric pressure (4 to 5 cm H2O below during expiration, 8 to 10 cm H2O below during inspiration)
• Lungs will collapse if intrapleural pressure equals atmospheric pressure
• One or two thoracotomy tubes are inserted
• Anterior tube removes air from the pleural space
• Posterior tube drains serosanguineous fluid or purulent exudate
• Posterior tube is often larger to prevent occlusion
• Connected to a pleural drainage system with a water-seal to reestablish negative pressure
• Suction may be applied to the drainage system
• prognosis is variable based on the patient's health

Nursing Interventions and Patient Teaching for the Chest tubes

• Bed rest
• Frequent oral care
• Encourage effective cough and deep breathing
• Apply a large sterile dressing after thoracentesis and assess for drainage
• Ensure Patency of the chest tube system

Areas of Concern for Chest Tubes

• Ensure water in the water-seal chamber fluctuates when suction is applied
• No bubbling in the water seal (indicates an air leak)
• Assess for increased dyspnea and check chest x-rays for lung consolidation
• Note air leaks, and ensure tubing is secure and patent
• Monitor white blood cells, temperature, and presence of purulent drainage (infection)

Additional Considerations for Pleural Effusion

• Patient position on the unaffected side (but may be in any position of comfort as long as the water-seal remains below the chest)
• Never elevate the drainage system to the level of the patient's chest
• Facilitate coughing and deep-breathing at least every 2 hours and auscultate breath sounds frequently
• Document amount and characteristics of pleural fluid drainage
• Prevent accidental removal by securing connections
• Keep tubing straight and loosely coiled
• Do not let the patient lie on it; tubing should never be over side rails
• Administer antibiotics as ordered

Atelectasis

• Etiology/Pathophysiology is a common postoperative complication from a mucous plug where shallow breathing interferes with effective coughing
• Collapse of alveoli in the lung due to blockage or poor inflation that prevents the exchange of carbon dioxide and oxygen
• May be limited or larger areas of the lung

Causes of Atelectasis

• Ineffective clearance of secretions due to shallow breathing (hypoventilation)
• Mucous accumulation
• Prolonged bed rest and hypoventilation Compression in lung tissue by tumors
• Hypoventilation causes all or part of the lung to collapse and Mucous accumulation leads to bronchial obstruction
• Can lead to stasis pneumonia because the retained secretions can lead to bacterial growth

Clinical Manifestations of Atelectasis

• Tachypnea
• Fever
• Pleural friction rub
• Restlessness
• Hypertension

Assessment of Atelectasis

• Subjective: shortness of breath, air hunger, anxiety, and fatigue
• Objective:
  • Decreased breath sounds and crackles
  • Tachycardia & hypertension initially, followed by bradycardia & hypotension
  • Monitor respiratory rate and effort
  • Assess for altered LOC due to hypoxia

Diagnostic Tests for Atelectasis

• Serial chest x-ray reveals atelectatic changes
• Chest CT scan can detect compression and may reveal the underlying condition
• ABG may reveal PaO2 less than 80mmHg; pulse oximetry may reveal oxygen saturation less than 90%
• Bronchoscopy may reveal a bronchial obstruction

Medical Management of Atelectasis

• Requires chest tube insertion to re-expand lung
• Instruct to deep breath and cough
• Incentive spirometry 10 times/hr
• May require intubation with mechanical ventilation
• May require suctioning, coughing, and vigorous respiratory therapy
• Medications: bronchodilators, antibiotics, and mucolytic agents
• A bronchoscope can be used to remove thick secretions or mucous plug

Nursing Interventions for Atelectasis

• Focus on improving ventilation and preventing infection
• Assess ability to move secretions
• Humidify air and bronchodilators to loosen secretions
• Incentive spirometry, deep breathing and coughing
• Encourage adequate hydration
• Auscultate breath sounds
• Assess color, amount, and consistency of sputum
• Chest physiotherapy with postural drainage
• Identify patient's emotional support system
• Assess patient's ability to comply with prescribed regimen