Respiratory System & Influenza

• The presentation covers different aspects of the respiratory system.
• The topics are:
  • Influenza
  • Pneumonia
  • Tuberculosis
  • Restrictive Lung Disease
  • COPD

Learning Objectives

• Explain key terms and medical terminology related to selected respiratory disorders.
• Apply knowledge of the pathophysiology of selected respiratory disorders in the adult pneumonia, aspiration, lung abscess, TB, Lung CA, COPD, oxygenation and occupational diseases.
• Apply the nursing process in the maintenance of health and promotion of self care of the adult patient with respiratory disorders.
• Relate diagnostic tests to the patient with respiratory disorders.
• Apply pharmacotherapeutics to the treatment of the adult patient with respiratory disorders.
• Determine the normal developmental changes and the changes of aging as they pertain to the patient with respiratory disorders.
• Articulate nursing responsibilities regarding nutritional requirements of the patient with respiratory disorders.
• Develop health promotion and maintenance practices as they relate to the patient with acute and chronic respiratory disease.
• Determine unique teaching/learning needs of the patient with selected respiratory disorders.
• Demonstrate the ability to deliver dignified nursing care which considers the diverse cultural needs of the patient with respiratory conditions.
• Utilize verbal and non-verbal communication techniques effectively when delivering care to patients experiencing common health care deviations.
• Discuss principles of safety and efficient use of systems resources in the care of the patient experiencing common health care deviations related to air.

Nursing Health History

• Risk factors include:
  • Smoking and 2nd hand smoking
  • Family history
  • Genetics
  • Allergens/pollutants
  • Occupational exposure

General Signs and Symptoms

• Dyspnea is shortness of breath.
  • DOE means dyspnea on exertion.
• Orthopnea and PND (paroxysmal nocturnal dyspnea) may be cardiac, waking up suddenly and having extreme difficulty with breathing.
• Other general signs and symptoms:
  • Wheezing
  • Club Fingers
  • Cough may cause chest pain or is there chest pain when the person coughs.
  • Sputum production/ vs Hemoptysis- could be cardiac, pulmonary, nasal, stomach or gums
  • Cyanosis is a very late sign
  • Chest pain

Objective Assessment

• Symmetry: Normal antero-posterior to lateral (ratio 1:2) Assess spine.
• Respiratory pattern: Rate, depth, rhythm and accessory muscle use.
• Breathing Patterns:
  • Tachypnea- rapid >20.
  • Bradypnea- slow <10.
  • Hyperventilation- rapid deep breathing.
  • Apnea- periods of cessation (absence) of breathing or total cessation.

Assessment of Breath Sounds

• Normal breath sounds:
  • Vesicular: heard over lung fields, Insp > Exp
  • Bronchovesicular: heard in first and second interspaces anteriorly
  • Bronchial: heard over the manubrium
  • Tracheal: heard over the trachea
• There are three lobes on the right side of the lung and two lobes on the left.
• Abnormal (adventitious) breath sounds include:
  • Crackles (fine, coarse)
  • Wheezes
  • Friction rubs.

Changes with Aging

• Alveolar surface area decreases and elastic recoil decreases.
• Chest wall compliance and vital capacity decreases while residual volume increases.
• The efficiency of the O2/CO2 exchange and respiratory muscle strength decreases.
• Large bronchi and alveoli become enlarged, ciliary mobility decreases, and vascular resistance increases.
• The formula for Vital capacity is Total Volume + Inspiratory Reserve + Expiratory Reserve.

Crackles

• Primarily heard during inspiration.
• Conditions include:
  • CHF
  • COPD
  • PNA from collapsed or waterlogged alveoli
• Fine crackles: indicate beginning of fluid buildup or atelectasis
• Coarse crackles: indicate greater volume of fluid buildup
• Management involves managing fluids and promoting expectoration.

Wheezes

• Sonorous wheezes (rhonchi) are deep, low-pitched sounds during expiration caused by narrowed passages due to secretions.
• Sibilant wheezes are continuous, high-pitched, whistle-like sounds during both inspiration and expiration and occur due to narrowed passageways (secretions, broncho-spasms).
• Interventions include:
  • Deep breathing and cough
  • Hydration (2-3 liters per day)
  • Humidifying air
  • Mobilization of secretions
  • Possibly bronchodilation.

Friction Rub

• A creaking, leathery, grating sound heard at the end of inspiration and beginning of expiration.
• Caused by rubbing of inflamed pleural surfaces against lung tissue.
• Interventions include:
  • CXR to diagnose.
  • Anti-inflammatory medications.
  • Steroids.

Diagnostic Tests

• Pulmonary function tests: Also looking at height, weight and trending changes.
• Sputum (not saliva) tests: May need to suction or do during an endoscopy.
• Chest X-ray: Uses 2 views PA and Lateral, to view densities, fluid (pleural effusion), and collapse such as Pneumothorax or atelectasis.
• Blood Cultures.
• Pulse Oximetry: Desired range is 95-100%.

Other Diagnostic Tests:

• Computed tomography (CT).
• Magnetic resonance imaging (MRI).
• Fluoroscopic studies and angiography- Dyes.
• Radioisotope procedures (lung scans).
• V/Q scan (Ventilation perfusion abnormalities).
• Gallium scan (Inflammations, abscess).
• PET (Cancer nodules).
• Biopsies.

Thoracentesis

• Used to remove pleural fluid to improve O2.
• Can also be used to collect:
  • Biopsies.
  • Cultures.
  • Cytology.
• Instills medication to treat pneumothorax.
• Requires pressure, bed rest, and CXR after the procedure.
• Monitor for complications such as distress, asymmetry, bleeding, and infection.
• In cases of cancer, cytotoxic meds can be instilled directly.

Arterial Blood Gases and ROME

• Measures arterial O2 and CO2 levels.
• Assesses adequacy of alveolar ventilation and ability of the lungs to provide O2 and remove CO2.
• Also assesses acid-base balance and kidney function.

Nursing responsibilities pre & post-bronchoscopy

• Surgical consent is required.
• Patient NPO for 6 hours pre procedure.
• Remove dentures.
• Patient education involves IV Local Anesthetic.
• Preop meds include: conscious Sedation/ Atropine.

Cold vs the Flu

• Cold symptoms include a rare fever, rare headache, slight aches and pains, quite mild weakness and fatigue, no exhaustion, common stuffy nose, usual sneezing, common sore throat, mild to moderate chest discomfort and hacking cough.
• Flu symptoms include:
  • Characteristic, high (100-102 degrees F) fever lasting three to four days.
  • Prominent headache.
  • Usual aches and pains that are often severe.
  • Fatigue and weakness that can last up to two to three weeks.
  • Early and prominent exhaustion.
  • Sometimes a stuffy nose.
  • Sometimes sneezing.
  • Sometimes a sore throat.
  • Common chest discomfort that can become severe.

Influenza

• Highly contagious infection that spreads rapidly from one individual to another.
• Influenza A is most severe due to mutation.
• Mutation of flu viruses makes people susceptible lifelong.
• Risk factors include old or young age, occupation, close living quarters, immunocompromise, chronic illness, and pregnancy.
• Influenza infection is the aerosolization of small droplets.
• Fomites are inanimate objects carrying organisms and facilitate transfer from one person to another, like stethoscopes, scissors, or pens.

Influenza Treatment & Complications

• Prevent by annual vaccination.
• Treatment includes:
  • Antipyretics/analgesics for fever and aches.
  • Adequate fluid intake to avoid dehydration.
  • Rest.
• Antiviral medications can be used for prophylaxis or treatment.
  • Should be started within 24-48 hours of symptom start.
• A major complication of influence is progressive SOB, persistent fever, and cardiovascular compromise, bacterial pneumonia and Streptococcus pneumoniae.

Antivirals

• Rimantadine (Flumadine): Used to control outbreaks of Influenza A
• Oseltamivir (Tamiflu): Used to treat flu virus
  • Reduces recovery for 1-2 days
  • Can be taken with or without food
  • Rare but serious life-threatening arrhythmias.
• Amantadine (Symmetrel): Blocks the uncoating of the virus, preventing penetration to the host
  • Side effects include dizziness, lightheadedness, nervousness with anxiety, and inability to concentrate.
• Zanamivir (Relenza)
  • Disk inhaler delivery system.
  • Use cautiously with COPD and asthmatic patients.

Pneumonia- PNA

• A most common cause of death amongst the elderly.
• Signs include:
  • Obstruction of Bronchioles
  • Reduced Gas Exchange
  • Increased Exudate
• Symptoms include:
  • Cough.
  • Fever
  • Chills
  • Tachycardia
  • Tachypnea
  • Dyspnea
  • Pleuritic pain.
  • Malaise
  • Respiratory Distress
  • Decreased breath sounds.

Types of Pneumonia (PNA)

• CAP: Community Acquired Pneumonia- within 48 hours after Hospitalization
• HCAP: Health Care Associated Pneumonia (Multi Drug Resistance)
• HAP: Hospital Acquired Pneumonia
• VAP: Ventilator Acquired Pneumonia
• Aspiration Pneumonia: Aspiration- Careful with Tube Feedings Staph pneumoniae, H. Influenza, Staph aureus), or stomach contents, chemicals, gases.
• PCP: Pneumocystis Jirovecii Pneumonia (immunocompromised people)

Pathophysiology of PNA

• Organisms enter via airways or bloodborne route and become trapped in the pulmonary capillary bed
• Acute inflammation of the Lung Parenchyma (Lung Tissue): Most are bacterial but also viral with kids
• Microbes spread in alveoli activating an inflammatory and immune response
• Edema occurs due to Antigen/ Antibody Ag/Ab response- damage to membranes of bronchioles and alveoli (Antigen- Exposure, Antibody- Reaction)
• Cellular debris and exudate fill/clog alveoli resulting in impaired gas exchange

Pneumonia- Outcomes/ Goals of care

• Goals include:
• Improved airway clearance
• Adequate rest and energy conservation
• Adequate fluid volume
• Adequate nutrition
• Knowledge of care an future prevention
• Absence of complications
• Prevention of complications:
  • Septic shock
  • Respiratory failure
  • Plueral effusions
  • Empyema

Aspiration

• Occurs when the protective airway reflexes are decreased or absent resulting in inhalation of foreign material (e.g., oropharyngeal or stomach contents, colonized oral or pharyngeal material) into the lungs causing pneumonia.
• Complication of aspiration that can cause pneumonia can result in tachycardia, dyspnea, central cyanosis, hypertension, hypotension, and potentially death.
• Primary factors responsible for death and complications after aspiration are the volume and character of the aspirated contents.
• The pathologic process involves an acute inflammatory response to bacteria ad bacterial products.
• Most commonly, the causative organisms in community-acquired aspiration pneumonia may include S. aureus, S. pneumoniae, H. influenzae, and Enterobacter species.

Prevent Aspiration

• Maintain head-of-bed elevation at an angle of 30 to 45 degrees, unless contraindicated
• Use sedatives as sparingly as possible
• Before initiating enteral tube feeding, confirm the tip location
• For patients receiving feedings, assess placement of the feeding tube at 4-hour intervals, assess for gastrointestinal residuals (<150 mL before next and prior feeding) to the feeding intervals
• For patients receiving tube feedings, avoid bolus feedings in those at risk for aspiration
• Evaluate swallowing before starting of oral feedings for patients who were recently extubated but were previously intubated for >2 days
• Maintain endotracheal cuff pressures at an appropriate level, and ensure that secretions are cleared from above the cuff before it is deflated

Lung Abscess

• Characterized as localized collection of pus caused by aspiration of anerobic bacteria.
  • The chest x-ray demonstrates a cavity of at least 2cm
• Risk factors:
  • Impaired cough reflexes
  • CNS disorders
  • Substance use disorder
  • Compromised immune function
  • Patients without teech and getting tube feedings
  • Ptents with altered consciousness d/t anesthesia
• Most are caused by aspiration of oral anarerobes into the lung due to mechanical or functional obsctruction of the bronchi by a tumor, foreign body, bronchial stenosis or from necrotizing pneuimnias, TB or pulmonary embolism (PE) or chest trauma.

Tuberculosis (TB)

• One third of the world is infected with TB, it's a leading cause of death from infectious disease.
• TB was formerly called consumption. Is communicable.
• Affects the lungs, but it can affect other areas of the body such as kidneys, bone and cerebral cortex.
• Occurs 2-10 weeks after exposure
• Transmission is airborne/droplet spread.
• Mycobacterium Tuberculosis is the bacteria.
  • Acid-fast gram-positive bacillus that is light and heat sensitive.
• Ghon tubercule on CXR occurs.
  • A granulomatous mass that is fibrous & dormant until it reactivated, ulcerates, and spread.
  • Calcification remains of the primary lesion.

Risk factors for TB

• Risk factors include:
  • Medically underserved
  • Recent immigrants from countries with high rate of TB
  • Domestic or occupational contact with TB- health workers
  • Long term care facilities, prisons, shelters
  • Frequent close contact to infected persons
  • Alcoholics and IV drug abusers
  • Chronic disease persons that are immunosuppressed

Mantaux Test

• Interpret within context of social history.
  • +5 mm with HIV or Immunosuppressed.
  • +10 mm if high risk job, children < 4- HR living or work environment
  • +15 mm in anyone else- no risk factors
  • If +10 mm, CXR within 72 hours.
  • If symptomatic, Sputum culture X3
• Will be a false positive with BCG vaccine which has been given in Canada, Europe, Latin America.
• False negs- immunosuppressed, recent live virus vaccination such as measles or smallpox
• Anergy- False negative due to the inability to produce a reaction

TB - Diagnostic Studies

• PPD for screening (two step protocol for new employees.
• CXR - Baseline if positive
• Sputum gram stain - Acid-Fast bacillus or M Tuberculosis.
• QuantiFERON-TB Gold Test - Not affected by the BCG vaccine.

TB - Medication combinations

• Active Disease Treatment:
  • Initial- Isoniazid (INH), Rifampin (RIF) Pyrazinamide(PRZ) & ethambutol X 8 weeks
  • Continuation- INH, RIF for 18 weeks, Vitamin B6 50 mg
• Latent Disease- PROPHYLAXIS. INH for 6-9 months, decrease Vit B6. High risk- INH for 12 months
• Mask in public and is non-infectious after 3 negative cultures.
  • Decreased transmission risk after 3 weeks of antibiotics.
  • (http://www.cdc.gov/tb/publications/factsheets/default.htm)

Nursing care of patient with TB

• Private room with negative airflow system.
• Specially fitted N95 Respirator Mask, Masks for visitors.
• Gowns and masks for secretions.
• Infection control and medication compliance is key
• Airway clearance occurs from Sputum cultures.
• Activity promotion and Nutrition

Occupational Lung Diseases; Pneumoconioses

• Caused by exposure to mineral or inorganic dust damaging the parenchyma and causing pulmonary fibrosis.
• Examples; coal miners, talc, toxic fumes
  • The cumulative effect is made worse by smoking
• The OH Nurse is the employee advocate
• Role of nurse in health education and in teaching preventative measures
• Role of implementing OSHA standards

Restrictive Lung Diseases

• Coal Worker's pneumoconiosis- Black Lung Disease
• Silicosis is an often fatal lung disease caused by breathing dust with silica particles.
• Asbestosis dust from demolition sites a risk for lung CA.
• Progressive and destructive
• part of insulation products that have now been taken off the market

Restrictive Lung Diseases Prevention and Causes Lung CA (bronchogenic carcinoma)

• #1 cause CA death in people in their 50's
• Causes By a single cell d/t tendency to arise from damaged tissue (fibrosis) d/t :
  • Cigarette smoking, Radon, Asbestos
• Diet: d/t few Fruits and Vegetables

Classification of Lung Cancers - Type of CA

• Small cell -10-15% ns Non small -85-90%. Squamus Cll - centrally - Bronchi
• Large Cell- Fast, Prefferaly
• Adeno- All over and more prevalent
• Bronchial - Alveolar is smaller but grows fast.

Lung Cancer Stages

• Size of Tumor location, involvement and or if metastasis has occured.
• Often has metasticiszed to Lymph nodes
• Stage 1- best outcome with increased cure.
• 4- Metastatic.

Lung Cancer - Common SX

• Cough, hoarseness, wseizing, Recurrent PNA, Swelling, Weight loss, Fatigue, Chest and or shoulder pain.
  • cough change
  • hemoptysis
  • SOB

Lung Cancer - Diagnosis

• Chest X-Ray Pulmonary Density
• Fine needle Aspiration
• Bronch
• Sputum - rare
• SCan Saller nodules

Management of lung cancer

• Treatment Includes Palliative measures - end stage.
• Surger, Raditation, Chemotherapy, Stints.

Lung CA - Nursing Care

• Psych Care -pain - pulmonary
• Airway, fatigue, dysmia and positioning as well as oxygen as nessecary.

Chronic Obstructive Pulmonary Disease (COPD)

• (GOLD) is the current initiative to characteriszed COPD
• COPD is the 4th leading cause of death in the U.S
• COPD can either include diseases that cause airflow obsctruction (emphysema, bronchiolits) or combination.
• Asthma is now considered a seperate disorder, but can exist.
  • Irreversible with Global Initiative for Chronic Lung Disease.
    • a disease state characterized by airflow limitation that is not fully reversible

Pathophysiology of COPD

• Airflow limitation and progressive condtion
• Irritation of airways results in inflammation and hypersecretion of mucus.
• Scar tissue and narrowing occur in the airways.
• This increased Pulm vasculature

COPD- Chronic Bronchilitis

• Cough and sputum production for at least 3 months in each of 2 consecutive years.
• Chronic inflammation from irratation of of airdways resuts in inflammation and hypersecretion of mucus.
• The hyper Plasi of Mucas gland.
• Cilia Disapear and aleoi get damaged.
• Results in increase is susceptibility to respiroty infections

Emphysema

• Problem in With exhalation
• Minimal sputum, Barrel chest and pink skin with pursed lips
• High 02 and low CO2
• Distention beyond the airways
• Dead spack decrease a,d traiping occers
  • Harder to breathe.
• The structure is desoryd, lung volume increase and may reslut in an abnormal posture like barrel chest.

COPD - Risk Factors

• Most associated with tobacco smoke causing COPD cases up to 90%!
• Risk of passive smoking, occupational exposure, ambient air pollution and genetic abnormalities

COPD - Medical management of risk

• Surgical management like a Balitomy - Lung volume redcation - transplant and O2

COPD - Nursing considerations

• Provide lung volumes, avoid extreme temps., breathing exericise and rehab to promote activity tolerence.
• Improve quality of ADL
• Improve gas exchange like proper admin, of dilators with huff coughing, irritant recution, PTD, O@ with O@ toxicity considerations
• Teach to watch their medication intake or if new sx
• Give the opportunity to talk about end of life issues .

Assess your knowledge of respiratory rates, breath sounds, and lung anatomy. Questions also cover influenza prevention, treatment, complications, and medications like Amantadine and Zanamivir. This quiz tests understanding of pneumonia and Mantoux test interpretation.