Respiratory Health: Chronic Conditions

• Supporting Health IV focuses on respiratory health challenges in individuals with chronic conditions.

Class Objectives

• Nursing management of pharmacotherapeutic regimens for individuals with chronic respiratory disorders across the lifespan is essential.
• Nursing interventions are important for patients and their families.
• A nursing care plan can provide a comprehensive approach to treatment.
• Collaborative approaches are needed to support self-management and effective coping with chronic respiratory disorders.
• Topics covered include Bronchopulmonary Dysplasia, Cystic Fibrosis, End-stage COPD, Interstitial Lung Disease, Pulmonary artery hypertension, and Lung Transplantation.

Bronchopulmonary Dysplasia (BPD)

• BPD is a chronic lung disease common in preterm neonates treated with oxygen and positive-pressure ventilation.
• Those with it have a higher risk of lung infections and chronic lung issues.
• Treatments involve antibiotics, corticosteroids, diuretics, electrolyte replacement, and bronchodilators.

Bronchopulmonary Dysplasia: Therapeutic Interventions

• Surfactant therapy prevents and treats BPD.
• Surfactant is a lipoprotein that reduces surface tension in the alveoli.
• Administered through an endotracheal tube in liquid form.
• Neonates require high calories for growth and healing; total energy may need to be >130 kcal/kg/day, and protein intake requirements are generally 3.5-4 g/kg/day
• A modest fluid restriction with high caloric density may be prescribed.
• Oxygenation targets Sp02 between 90-95%, avoiding high (>95%) and low oxygenation.
• Infants may experience sudden episodes of pulmonary decompensation which can be identified by worsening gas exchange and respiratory distress.
• Decompensation can be caused by bronchospasm, fluid retention in the lungs, pulmonary air leak, endotracheal tube displacement, or symptomatic tracheobronchomalacia.

Cystic Fibrosis

• Interventions for growth and development in infants includes targeted nutrition for increased height and weight.
• Goals of interventions are to minimize pulmonary complications, ensure adequate nutrition for growth and appropriate physical activity, and maintain a reasonable quality of life for the child and family.
• Therapeutic pharmacological interventions for Cystic Fibrosis include CFTR modulator therapy, Airway Clearance Therapies (hypertonic saline DNase), intermittent antibiotic therapy as needed, and glucocorticoid therapy as needed
• Colonization of MRSA is a critical factor requiring longer hospital stays

Cystic Fibrosis: Therapeutic Interventions for Pulmonary Issues

• Include Antibiotic Therapy, Airway Clearance Therapies (hypertonic saline DNase), Oxygen as needed, and Chest physiotherapy.
• Viscous secretions are conducive for bacterial growth.
• Colonization of MRSA is a critical factor in recovery and longer lengths of hospital stays.

Cystic Fibrosis: Non-Pharmaceutical Interventions

• Essential for illness prevention and treatment, especially chest physiotherapy.
• Chest physiotherapy typically occurs twice daily, including 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 for children and families.
• 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.
• Peripherally/centrally inserted vascular access devices, feeding tubes (NG, G-Tube), and oxygen and nebulizer equipment are invasive lines that cause stress.

Cystic Fibrosis: Interventions for GI Issues

• Energy requirements are typically at least 150% of recommended daily allowances.
• Replacement of pancreatic enzymes (1-5 pills/meal), goal of max 1-2 stools/day.
• Prolapse of the rectum is associated with large bulky stools.
• Individuals are at risk for bowel obstruction.

Cystic Fibrosis: Interventions for Endocrine Issues

• Cystic fibrosis related diabetes (DFRD) is the most common complication in children.
• Insulin is recommended; oral hypoglycemics are not effective
• Ketoacidosis is rare.
• By age 30, 50% of CF patients have diabetes.
• High fat, high calorie diet is still recommended.

Cystic Fibrosis: Interventions for Sexuality

• Discussions around fertility issues.
• 95% of males have congenital absence of vas deferens but important distinction - they are not impotent.
• Assisted reproductive technology is usually required for males.
• Females are less fertile due to highly viscous cervical secretions, with lower conception rates.
• Genetic counseling is highly advised.
• Females have a higher incidence of low-birth-weight babies and spontaneous abortions.

Adult Lung Disease

• Adult Lung Diseases include the following:
• Chronic Obstructive Pulmonary Disease
• Interstitial Lung Disease

Chronic Obstructive Pulmonary Disease: Clinical Manifestations

• Dyspnea
• Cough (with or without sputum)
• Sputum production
• Wheezing / prolonged expiration
• Hypoxia

Chronic Obstructive Pulmonary Disease: Complications

• Exacerbation of COPD is marked by worsening dyspnea and/or cough and sputum production for up to 14 days, often caused by airway infection, pollution, or other irritants.
• Symptoms that change acutely during an exacerbation is more frequent/severe cough, increased/changed sputum, and more intense dyspnea.
• Other complications include hospitalization, hypercapnia, hypoxia (secondary polycythemia), exacerbation +/- respiratory failure, excessive sputum/mucous production contributing to pneumonia risk, and general weakness affecting coughing, air expulsion, and puffer use.
• Patients are at risk of Chronic anemia, fatigue, malnutrition, cachexia, sarcopenia, skeletal muscle dysfunction, pulmonary hypertension, right heart failure, anxiety/panic attacks and depression

COPD: Pharmacological Interventions

• Short-acting inhaled bronchodilators: SABAs (Ventolin), SAMAs (Ipratropium)
• Long-acting inhaled bronchodilators: LABA (salmeterol), LAMA (tiotropium)
• +/- Inhaled Glucocorticoids (Pulmicort)
• +/- Oral/intravenous glucocorticoids (prednisone/methylprednisolone)
• +/-Antibiotics

COPD: Gas Exchange

• Oxygen is always considered a medication.
• The drive to breathe is based on arterial CO2 levels.
• General goal of 02 therapy is to titrate the flow rate to achieve Sa02 between 88% and 92%.
• Never administer >6L of 02 per facial mask as this lack of flow will prevent proper clearance of CO2 potentially causing hypercapnia.
• Use caution administering nebs via masks.
• Account for CO2 toxicity when monitoring COPD patients.
• Be mindful of situations where CO2 retention can be potentiated.
• Smoking with 02 is dangerous so patients should be educated.
• Portable oximeters can be purchased.

COPD: Air Trapping

– Nurses should encourage purse-lipped breathing and tripoding for dyspnea. – Recommended breathing exercises include the Huff Cough and Pursed Lip Breathing techniques.

COPD: Bilevel Positive Airway Pressure (BIPAP)

• Used during non-invasive positive pressure ventilation (NPPV).
• Delivers a pre-set inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure (EPAP).
• Tidal volume correlates with the difference between the IPAP and the EPAP.
• CPAP (Continuous Positive Airway Pressure) is NOT the same as BIPAP.
• CPAP applies minimal pressure to resolve apneas, snoring, and/or obstructive events in the upper airway; it doesn't treat hypercapnia.

COPD: Non-Pharmacological Intervention Patient Education

• Risk factors should be reduced (smoking cessation) to prevent progression and avoid exposure to irritants.
• Education equips patients with knowledge of what will support symptom relief and slow disease progression; ensure assessment/education on inhaler technique.
• Self-care strategies include maintaining activity to prevent deconditioning, build resilience, and address emotional well-being.
• Those with COPD should consume energy requirements (1.2-1.3x the normal kcal) and frequent meals to avoid pressure/discomfort on the diaphragm.
• Avoid foods that produce flatus, ensure adequate hydration and eat a high-calorie, high-protein (minced) diet.
• Supplemental oxygen and C02 education include purchasing portable Sa02 oximeters.
• Signs and symptoms of concerns should be communicated to the healthcare team to support intervention.
• Recommended infection prevention vaccines, hand hygiene and avoiding contagious people.

COPD: Non-Pharmacological Interventions to Preserve Energy

• Avoid meal prep immediately prior to meals to conserve energy.
• Consider using a SABA (Ventolin) before to help prevent dyspnea during sexual activity.
• Patients should discuss any related questions or concerns with their healthcare provider.
• Get sleep/frequent naps.
• Practice relaxation techniques can help with stress, depression, anxiety, etc.

COPD: Surgical Interventions

• Lung volume reduction surgery.
• Lung transplantation.

COPD: Palliative Care

• It's vital for patients and loved ones to express their feelings and encourage patients to express their values, fears, and questions.
• Nurses within the team can make the MRHP aware of palliative care/spiritual needs and advocate for consults.

Interstitial Lung Disease: Clinical Manifestations

• Progressive dyspnea with exertion.
• Persistent non-productive cough.

Interstitial Lung Disease: Idiopathic Pulmonary Fibrosis Therapeutic Interventions

• Supplemental oxygen.
• Education about the progressive/terminal condition, and palliative care principles.
• Pulmonary Rehab
• Prevention of infections and acute exacerbations (avoid crowds/contagious people, and get respiratory infection vaccines)
• High concentrated nutrition (small, frequent meals and nutritional supplements).

Interstitial Lung Disease: Pharmacologic Interventions

• Antifibrotic Therapy for Idiopathic Pulmonary Fibrosis
• Nintedanib (Ofev): A receptor blocker for multiple tyrosine kinases that mediate the elaboration of fibrogenic growth factors; slows the rate of disease progression
• Pirfenidone (Esbriet): Inhibits transforming growth factor beta (TGF-b) stimulated collagen synthesis, decreases the extracellular matrix, and blocks fibroblast proliferation in vitro.

Pulmonary Hypertension (Group 3)

• Obstructive lung disease (i.e., COPD).
• Restrictive lung disease (i.e., ILD).
• Mixed obstruction and restriction (i.e., pulmonary fibrosis with emphysema).
• Hypoxia without lung disease.
• Developmental lung disorders (Bronchopulmonary Dysplasia).

Pulmonary Hypertension: Interventions

• Treatment of underlying condition(s).
• Exercise as tolerated.
• Routine vaccinations.
• Counseling against smoking.
• Supportive measures, where indicated: Oxygen (for confirmed hypoxemia) and Diuretics.

Cor Pulmonale (Right Heart Failure): Therapeutic Interventions

• Right-side hypertrophy with or without heart failure.
• End result of pulmonary HTN.
• Address pulmonary issues, provide long-term oxygen therapy, administer diuretics if indicated, recommend a low-sodium diet while watching sodium levels, and palliative measures if clinically indicated.

Lung Transplant: Postoperative Care and Interventions

• Includes ventilator support, bronchodilators, chest physio, DB & C, fluid and hemodynamic monitoring, immunosuppression, detection and assessment of early rejection, monitoring infection, Chest tube/trach care, Infection surveillance, Anticoagulation therapy once hemodynamically stable, Nutritional support, and Wound care.

Lung Transplant: Therapeutic Interventions

• Psychological screening ensures patient and family can cope with postoperative regime.
• Immunosuppression therapy is achieved through a triple regime of cyclosporine, azathioprine and prednisone.
• Rejection is diagnosed by biopsy through bronchoscopy.
• Acute rejection occurs in 5-7 days, treated with corticosteroids.
• Chronic rejection involves bronchiolitis obliterans, treated with immuno-suppression.

Respiratory Interventions

• Tracheotomy
• Surgical incision into trachea.
• Creates an artificial airway into the trachea.
• Indications: Bypass upper airway obstruction, facilitate removal of secretions, for long-term ventilation, and allows oral intake/speech in long term ventilated patients.
• Safety: Keep extra kit at bedside, know cuffed vs uncuffed, cuff pressure should not exceed 20 mm HG, determine routine vs accidental decannulation, and cuff must be deflated for vocalization.

Tracheostomy

• A fenestrated trach cannula requires the patient be able to cough up secretions, and allows vocalization and spontaneous breathing.
• Decannulation involves plugging the trach, requiring the patient to exchange air and expectorate secretions.
• The stoma is closed with steri-strips, and the patient should splint stoma while coughing.
• During accidental decannulation, do not attempt to re-insert the trach tube; get help immediately.
• Assess respiratory status and apply oxygen over mouth/stoma, call NP/physician, cover stoma during repiratory distress/provide 100% oxygen with BVM, a RT/Physician will re-insert the tube and may need obturator from bedside.
• Must ensure a spare trach that is one size smaller is available from safety kit.

Long COVID

• Includes physical and mental symptom clusters that persist for at least three months from the onset of illness
• Vaccination has been associated with lower incidence.
• Recommendations are to treat underlying cardio or pulmonary disease, and provide supportive measures that are individualized to the patient.
• Inpatient and outpatient (including online) rehabilitation programs are available.
• Screening Tools have been used to assess patient progress over time.
• For mild dyspnea - Breathing exercises/breathlessness management strategies
• For moderate – severe dyspnea - > referral to pulmonary specialist - > specialized pulmonary rehabilitation program
• Corticosteroids may be helpful.
• Cough suppressant therapy can be used with caution.
• For Chest discomfort/tightness/pain (confirmed as long COVID): NSAIDs should be used judiciously, and carefully with renal dysfunction.
• Specialty Consultantations as needed and VTE prevention as indicated.
• Fatigue: “Four-P Approach” to energy conservation: Planning, Pacing, Prioritizing, Positioning
• Orthostasis: compression stockings, abdominal binder, hydration, physical therapy, and behavioral modifications may be indicated.
• Olfactory/Gustatory: time, in some instances olfactory training and self-guided programs may be indicated.
• Psychological and emotional issues: In cases of PTST, psychiatric consultation may be necessary. Additionally, support is available through social work; inpatient/outpatient resources based on context.