Care of Clients with Oxygenation Problems PDF

Care of Clients with Problems in Oxygenation Marlon A. Allecer, RN Respiratory systems disorder  II. Management of Patients with Upper Respiratory Tract Disorders 1. Describe nursing management of patients with upper airway disorders. 2. Discuss upper respiratory tract infections...

Care of Clients with Problems in Oxygenation Marlon A. Allecer, RN Respiratory systems disorder  II. Management of Patients with Upper Respiratory Tract Disorders 1. Describe nursing management of patients with upper airway disorders. 2. Discuss upper respiratory tract infections according to cause, incidence, clinical manifestations, and management. 3. Use the nursing process in caring for patients with upper airway infection Respiratory systems disorder III. Management of Patients with Chest and Lower Respiratory Tract Disorders 1. Compare the various pulmonary infections with regard to causes, clinical manifestations, nursing management, complications, and prevention. 2. Describe preventive measures appropriate for controlling and eliminating occupational lung disease. Respiratory systems disorder IV. Management of Patients with Chronic Pulmonary Disease 1. Describe the pathophysiology, clinical manifestations, treatment, and medical and nursing management of chronic pulmonary diseases 2. Discuss the major risk factors for developing chronic obstructive pulmonary disease and nursing interventions to minimize or prevent these risk factors 3. Develop an education plan for patients with chronic obstructive pulmonary disease. UPPER RESPIRATORY DISORDERS Types of Rhinitis 1. Allergic Rhinitis - is the reaction of the nasal mucosa to a specific allergen. ❑Allergic rhinitis can be classified according to the causative allergen (seasonal or perennial) or, ❑ the frequency of symptoms (episodic, intermittent, or persistent). ❑ Episodic refers to symptoms related to sporadic exposure to allergens that are not typically encountered in the patient’s normal environment, such as exposure to animal dander when visiting another person’s home.  Allergic Rhinitis … ❑Intermittentmeans that the symptoms are present less than 4 days a week or less than 4 weeks per year. ❑Persistent means that the symptoms are present more than 4 days a week and for more than 4 weeks per year 7 By Abdi Wakjira( Bsc, Msc) 11/20/2024  Pathophysiology Sensitization to an allergen occurs with initial allergen exposure, which results in the production of antigen-specific immunoglobulin E (IgE).  After exposure, mast cells and basophils release histamine, cytokines, prostaglandins, and leukotrienes.  These cause the early symptoms of sneezing, itching, rhinorrhea, and congestion.  Four to 8 hours after exposure, inflammatory cells infiltrate the nasal tissues, causing and maintaining the inflammatory response.  Because symptoms of rhinitis resemble those of the common cold, the patient may believe the condition is a continuous or repeated cold.  Clinical Manifestations  Manifestations of allergic rhinitis are initially sneezing; watery, itchy eyes and nose; altered sense of smell; and thin, watery nasal discharge that can lead to a more sustained mucus production and nasal congestion.  The nasal turbinates appear pale,boggy, and swollen.  C/M is characterized by 4 cardinal symptoms of watery Rhinorrhoea, nasal obstruction, nasal itching and sneezing.  Clinical Manifestations Cont…d  The posterior ends of the turbinates can become so enlarged that they obstruct sinus aeration or drainage and result in sinusitis.  With chronic exposure to allergens, the patient’s responses include headache, congestion, pressure, nasal polyps, and postnasal drip as the most common cause of cough.  The patient may complain of cough, hoarseness, and the recurrent need to clear the throat. Congestion may cause snoring DIAGNOSIS OF Allergic Rhinitis The diagnosis of AR is based on a typical history of allergic symptoms and diagnostic tests. When 2 or more symptoms out of watery Rhinorrhoea, sneezing, nasal obstruction and nasal pruritus persist for ≥1 hour on most days, Allergic Rhinitis is strongly suspected Skin testing Skin testing is the most important to find offending allergens. There are various testing methods including the scratch, prick/ puncture, intradermal and patch tests.  The radioallergosorbent test (RAST);Serum specific IgE level Multiple allergen simultaneous test (MAST); uses a photo reagent instead of a radioactive isotope, TREATMENT OF ALLERGIC RHINITIS  Requires a stepwise approach depending on the severity and duration of symptoms.  Treatment options for AR consist of a) Allergen avoidance, b) Pharmacotherapy, c) Immunotherapy and d) Surgery. The four major categories of medications used to manage cold symptoms are antihistamines, decongestants, antitussives, and expectorants.  Pharmacotherapy An over-the-counter (OTC), non-sedating antihistamine Competitively inhibit the interaction of histamine with H1 receptors. They prevent and relieve nasal itching, sneezing, and Rhinorrhoea, and ocular symptoms, e.g. Loratadine 10 mg once daily Desloratadine 5 mg once daily Cetirizine 10 mg once daily or divided BID Levocetirizine 5 mg once daily in the evening Intranasal corticosteroids Are potent inhibitors of the late-phase allergic reaction in Allergic Rhinitis. They inhibit recruitment of Langerhans cells, macrophages, mast cells, T cells, and eosinophils into the nasal mucosa They control itching, sneezing, Rhinorrhoea, and stuffiness E.g. Beclomethasone dipropionate 2 sprays EN/day Fluticasone (Flonase), 1–2 sprays EN /day Decongestants ❖Decrease swelling of the nasal mucosa which, in turn, alleviates nasal congestion e.g. Oxymetazoline nasal spray Pseudoephedrine 60 mg every 4-6 h pills 120mg ER every 12h 240mg ER once daily  NURSING AND COLLABORATIVE MANAGEMENT  The most important step in managing allergic rhinitis is identifying and avoiding triggers of allergic reactions  The goal of medications is to reduce inflammation associated with allergic rhinitis, reduce nasal symptoms, minimize associated complications, and maximize quality of life.  Appropriate oral medication options include: H1-antihistamines, corticosteroids, decongestants, and leukotriene receptor antagonists (LTRAs).  NURSING AND COLLABORATIVE MANAGEMENT Cont …d  Second-generation antihistamines are preferred over first generation antihistamines because of their nonsedating effects.  Remind patients who are taking antihistamines to have adequate fluid intake to reduce adverse symptoms.  Nasal corticosteroid sprays are used to decrease inflammation locally with little absorption in the systemic circulation.  Therefore, systemic side effects are rare.  2. Non-Allergic Rhinitis This form of rhinitis does not depend on the presence of IgE and is not due to an allergic reaction. The symptoms can be triggered by cigarette smoke and other pollutants as well as strong odors, alcoholic beverages, and cold. Other causes may include blockages in the nose, a deviated septum, infections, and over-use of medications such as decongestants.  3. Acute viral Rhinitis  Acute viral rhinitis (common cold or acute coryza) is an infection of the upper respiratory tract that can be caused by more than 200 different viruses.  The majority of colds, which are caused by rhinoviruses, are mild and self-limiting.  Cold symptoms may last 2 to 14 days, with typical recovery in 7 to 10 days.  Caution patients to use the intranasal decongestant sprays for no more than 3 days to prevent rebound congestion from occurring.  Cough suppressants may be used.  3. Acute viral Rhinitis Cont…d  Complications of acute viral rhinitis include pharyngitis, sinusitis, otitis media, tonsillitis, and lung infections.  Unless symptoms of complications are present, antibiotic therapy is not indicated.  If symptoms remain for 10 to 14 days with no improvement, acute bacterial sinusitis may be present, and antibiotics will be prescribed.  Teach the patient to recognize the symptoms of secondary bacterial infection, such as a temperature higher than 100.4° F (38° C); tender, swollen glands; severe sinus or ear pain; or significantly worsening symptoms.  Sinusitis Four pairs of paranasal sinuses 1. Frontal-above eyes in forehead bone 2. Maxillary-in cheekbones, under eyes 3. Ethmoid-between eyes and nose 4. Sphenoid-in center of skull, 11/20/2024 21 behind nose and eyes  Sinusitis--- An acute inflammatory process involving one or more of the paranasal sinuses. A complication of 5%-10% of URIs in children. Persistence of URI symptoms >10 days without improvement. Maxillary and ethmoid sinuses are most frequently involved. 11/20/2024 22  Types of Sinusitis It is typically classified by:_  Duration of illness (acute vs. Chronic)  Etiology (infectious vs. Noninfectious)  Pathogen type (viral, bacterial, or fungal) 1. Acute Sinusitis – respiratory symptoms last longer than 10 days but less than 30 days. 2. Sub acute sinusitis – respiratory symptoms persist longer than 30 days without improvement. 3. Chronic sinusitis – respiratory symptoms last 11/20/2024 23 longer than 120 days.  Pathophysiology of sinusitis Rhinitis or abrupt pressure changes (air planes, diving) or dental extractions or Inflammation infections. and edema of mucous membranes lining the sinuses cause obstruction. With inflammation, the mucosal lining of the sinuses produce mucoid drainage. Bacteria invade and pus accumulates inside the sinus cavities. Postnasal drainage causes obstruction of nasal passages and an inflamed throat. If the sinus orifices are blocked by swollen mucosal lining, the pus cannot enter the nose and builds up pressure inside the sinus cavities 11/20/2024 24  Predisposing Factors ⧫Allergies, ⧫Cold weather ⧫High pollen counts ⧫Day care attendance ⧫Smoking in the home ⧫Reinfection from siblings 11/20/2024 25  Predisposing Factors ⧫Anatomical: septal deviation, nasal deformities, nasal polyps ⧫Mucociliary functions: cystic fibrosis, immotile cilia syndrome. ⧫Systemic disease: immune deficiency.: DM, AIDS, ⧫Neoplasia 11/20/2024 26  Etiology Acute sinusitis Chronic sinusitis Str. pneumoniae Anaerob bacteria: %41 ✓ Bactroides, H. influenzae %35 fusobacterium M. catarrhalis %8 ✓ S. Aureus Others %16 ✓ Strep. Pyogenes ✓ Strep. pyogenes ✓ Str. Pneumoniae ✓ S. aureus ✓ Gram (-) bacteria ✓ Rhinovirus fungi ✓ Parainfluenzae ✓ Veilonella, peptococcus 11/20/2024 27 Signs and Symptoms Headache, congestion, facial pain, fatigue, and cough, Purulent nasal discharge. Pain over the region of the affected sinuses If a maxillary sinus is affected, the patient experiences pain over the cheek and upper teeth. In ethmoid sinusitis, pain occurs between and behind the eyes. Pain in the forehead typically indicates frontal sinusitis. Fever may be present in acute infection, with or without generalized fatigue and foul breath. 11/20/2024 28 Diagnosis of sinusitis History ;persistent symptom of URI and physical findings Radiographic studies Opacification and mucosal thickening air filled level Others : Translumination of sinus cavity Sinus aspirate culture Nasal endoscopy If repeated episodes occur:- ✓ x-ray examination ✓ computed tomography (CT) scan ✓ magnetic resonance imaging (MRI) 11/20/2024 29 Treatment of Sinusitis Nondrug measures : ❖ Maintain adequate hydration(drink 6-10glasses of liquid ) ❖ Personal Steam vaporizer ❖ Apply warm facial packs (warm wash cloth, hot water bottle) ❖ Saline irrigation lavage or sniff (1/4 teaspoon salt dissolved in 1cup of water ) ❖ Sleep ahead of bed elevated ❖ Adequate rest ❖ Avoid cigarette smoke and extremely dry or cool air 11/20/2024 30 Drug Treatment Antibiotics First-line: Amoxicillin, 1.5 to 3.5 g/d divided 2 or 3 times daily) Trimethoprim–sulfamethoxazole 800/160 mg twice daily Second-line: Amoxicillin–Clavulanate (500/125 mg 3 times daily) Second- or third-generation cephalosporin Cefuroxime, 250 or 500 mg twice daily, ❑ Doxycycline 200 mg on first day then 100 mg twice 11/20/2024 daily for 2 to 10 days 31  Antibiotics---- Macrolides : Clarithromycin, 500 mg twice daily or Azithromycin, 500 mg daily for 5 days Fluoroquinolones : Ciprofloxacin, 500 twice a day or Levofloxacin, 500 mg once daily Oral antihistamines :Loratadine, 10 mg daily Nasal decongestant: Xylometazoline intranasally, 2 to 3 sprays every 8 to 10 hr. Nasal steriods :Fluticasone, 2 puffs) intranasally [200 µg] daily Acetaminophen or ibuprofen is given for pain and fever. 11/20/2024 32 Nursing management Patient teaching self care Instruct patient to blow the nose gently and to use tissue to remove the nasal drainage. Increasing fluid intake, Applying local heat (hot wet packs), and Elevating the head of the bed promote drainage of the sinuses. Instructs the patient about the importance of medication regimen. 11/20/2024 33 Tonsillitis Tonsils are protective (lymph) glands that are situated on both sides in the throat. The tonsils constitute an important part of the body's immune system and are vital defense organs. They protect the body from bacteria and viruses by fighting these as soon as they enter the body (via the oral / nasal cavity). Inflammatory process of the mucosa and structures of the pharyngo-tonsillar area, usually of infectious origin Tonsillitis is contagious. It affects all ages, but is most common in children between ages 5 and 10 11/20/2024 34  Tonsillitis --- 11/20/2024 35  Clinical Manifestations Throat pain, either mild or severe. Swallowing with difficulty. Odynophagia, pharyngeal exudate, anterior cervicolateral lymphadenopathy, scarlet rash and headache Chills and fever as high as 104° F (40° C) or more. Swollen lymph glands on either side of the jaw. Ear pain. Cough (sometimes). Vomiting (sometimes). Refusal to eat in a very young child. Erythema, Edema, Ulcer or vesicles 11/20/2024 36  Causes of Tonsillitis ❖ Viruses: Rhinovirus, adenovirus, influenza virus, Para influenza virus,Coxsackie virus and Epstein- Barr virus ❖ Aerobic Bacteria: GABHS and other streptococcal species, Neisseria gonorrhoeae, Corynebacterium diphtheriae. ❖ Yeast :Candida species. Spirochetes:Treponema pallidum (syphilis) 11/20/2024 37  Causes ---- 11/20/2024 38  Assessment and Diagnostic Findings ✓ History :look at throat to see red and swollen tonsils with spots or sores. ✓ Throat culture: rapid strep test ✓ Blood test ;done to confirm presence of infection 11/20/2024 39  Medical Management Bed rest, except to use the bathroom, is necessary until fever subsides. DIET Supportive measures include Increase all fluid intake. While the throat is very sore, use liquid nourishment, such as milk shakes, soups, and high-protein fluids (diet or instant-breakfast milk drinks). Viral tonsillitis is not effectively treated with antibiotic therapy. Tonsillectomy if complicated 11/20/2024 40  Antibiotic treatment of choice  Penicillin V: 27 kg: 500mg / 12h 10 days  Penicillin G Benzathine: 27 kg: 1.200.000 UI, single dose 11/20/2024 41  Antibiotic treatment of choice  Amoxicillin: 50mg /kg/day, every 12-24 hours, 10 days, with a maximum dose of 500mg /12h or 1g/24h.  Mediated by IgE: - Azithromycin: 20mg/kg /day, once a day, 3 days (maximum 500mg/day) - Clindamycin: 20-30mg/kg /day, every 8-12h, 10 days (maximum 900mg/day). 11/20/2024 42  Indications for tonsillectomy Recurrent tonsillitis (more than seven per year Persistent, chronic tonsillitis Recurrent peritonsillar abscess with previous history of recurrent or persistent tonsillitis. Unilateral tonsillar hypertrophy. Hemorrhagic tonsillitis. Chronic tonsillolithiasis. Nasal obstruction with speech abnormalities, orodental abnormalities. 11/20/2024 43  Complications of tonsillitis  Classified into suppurative and nonsuppurative complications.  The nonsuppurative complications include Scarlet fever, Acute rheumatic fever, and Post-streptococcal glomerulonephritis. Suppurative complications include ❖ Peritonsillar, parapharyngeal and retropharyngeal abscess formation. 11/20/2024 44 Pharyngitis ACUTE PHARYNGITIS:is a sudden painful inflammation of the pharynx, the back portion of the throat that includes the posterior third of the tongue, soft palate, and tonsils. It is commonly referred to as a sore throat Causes ⚫ Viral infection- most common(adenovirus, influenza virus, Epstein-Barr virus, and herpes simplex virus) ⚫ Bacterial infection-Group A beta-hemolytic streptococcal bacterial infection called strep throat.  Cont….d Pathophysiology Viral/ strep throat infection The body responds by triggering an inflammatory response in the pharynx. This results in pain, fever, vasodilation, edema, and tissue damage, manifested by redness and swelling in the tonsillar pillars, uvula, and soft palate. A creamy exudate may be present in the tonsillar pillars If caused by GA hemolytic streptococcus- it may be severe If caused by uncomplicated virus- may be subside promptly(3 to 10 days after the onset). 46  Cont….d Complications Sinusitis Otitis media Peritonsillar abscess Mastoiditis Cervical adenitis In rare cases, the infection may lead to bacteremia, pneumonia, meningitis, rheumatic fever, and nephritis. 11/20/2024 47  Cont….d Clinical features Fiery-red pharyngeal membrane and tonsils Lymphoid follicles that are swollen and flecked with white-purple exudate, and enlarged Tender cervical lymph nodes No cough Fever Malaise Sore throat 11/20/2024 48  Cont….d 11/20/2024 49  Cont….d  Assessment and dxs Accurate diagnosis of pharyngitis is essential to determine the cause (viral or bacterial) Newer and more rapid diagnostic tests (eg, the rapid streptococcal antigen test (RSAT). Medical mgt For virus- supportive care For bacterial-penicillin is a drug of choice if allergic and resistance (clarithromycin and azithromycin) may be used. Analgesic medications, as prescribed( i.e. Aspirin or acetaminophen)can be taken 11/20/2024 50  Cont….d Nursing management Instructs the patient to:_ ❖ Stay in bed during the febrile stage of illness and ❖ Full course of antibiotic therapy Preventive measures ❖ Not sharing eating utensils, glasses, napkins, food, or towels; cleaning telephones after use ❖ Using a tissue to cough or sneeze ❖ Disposing of used tissues appropriately ❖ Avoiding exposure to tobacco and secondhand smoke. 11/20/2024 51 Cont….d Chronic pharyngitis:- is a persistent inflammation of the pharynx. Types ❖ Hypertrophic: characterized by general thickening and congestion of the pharyngeal mucous membrane ❖ Atrophic: probably a late stage of the first type (the membrane is thin, whitish, glistening, and at times wrinkled) ❖ Chronic granular (“clergyman’s sore throat”), characterized by numerous swollen lymph follicles on the pharyngeal wall 11/20/2024 52  Cont….d Common in person :_ work in dusty surroundings Use their voice to excess Suffer from chronic cough Habitually use alcohol and tobacco. Clinical manifestation Sense of irritation or fullness in the throat, Mucus that collects in the throat and can be expelled by coughing Difficulty swallowing. 11/20/2024 53  Cont….d Medical management Nasal congestion medications (ephedrine sulfate (Kondon’s Nasal) or phenylephrine hydrochloride) Antihistamine decongestant medications, such as Pseudoephedrine. For adults with chronic pharyngitis, tonsillectomy is an effective option. Nursing management Avoid alcohol, tobacco, secondhand smoke, and exposure to cold or to environmental or occupational pollutants. 11/20/2024 54 Larynxfrontsm LARYNGITIS 55  DEFINITION It is the inflammation of larynx leading to oedema of laryngeal mucosa and underlying structures.  ETIOLOGY INFECTIOUS:  Viral laryngitis can be caused by rhinovirus, influenza virus, parainfluenza virus, adenovirus, coronavirus, and RSV.  Bacterial laryngitis can be caused by group A streptococcus, streptococcus pneumoniae, C. diphtheriae, M. catarrhalis,haemophilus influenzae, bordetella pertussis, and M. tuberculosis.  Fungal laryngitis can be caused by Histoplasma, Candida (especially in immunocompromised persons) 57 NON-INFECTIOUS  Inhaled fumes  Acid reflux disease  Allergies  Excessive coughing, smoking, or alcohol consumption.  Inflammation due to overuse of the vocal cords  Prolonged use of inhaled corticosteroids for asthma treatment  Thermal or chemical burns  Laryngeal trauma, including iatrogenic one caused by endotracheal intubation Predisposing factors  Smoking  Psychological strain  Physical stress  Voice abuse misuse  Acid reflux (GERD)  Frequent sinus infectionsr  Types – acute (less then 3 weeks)and chronic (more than 3 weeks )  Pathophysiology  Due to etiological factors  The mucosa of the larynx becomes congested and may become oedematous.  A fibrinous exudate may occur on the surface.  Signs and symptoms  Sometimes infection involves the perichondrium of laryngeal cartilages producing perichondritis.  Types of Laryngitis  1. Acute Laryngitis  2. Chronic laryngitis 1. Acute laryngitis: Def: It is the inflammation of larynx which lasts less than a few days & leads to edema of laryngeal mucosa & underlying structures. Most cases of AL are temporary & improve after the underlying causes get better. 11/20/2024 61  Acute Laryn ….  Frequently caused by ‘Rhinovirus”  Other causative Organisms: ▪ Para influenza virus ▪ Respiratory syncytial virus ▪ Adeno virus ▪ Measles & Mumps ▪ Bacterial infection- such as Diphteria, these are rae. 11/20/2024 62   Vocal misuse, vocal strain or yelling or over use of the voice.  Exposure to noxious  Viral infections such as that cause a cold.  Frank aphonia 11/20/2024 63  Chronic Laryngitis  Laryngitis that lasts more than 3 weeks is known as chronic laryngitis.  More persistent disorder that produces lingering hoarseness & other voice changes  It is usually painless & has no significant sign of infection. 11/20/2024 64  Etiology  Vocal misuse  Exposure to noxious agent.  Infectious agents leading to upper respiratory tract infections. Most often viral but some times bacterial  Inhaled irritants such as chemical fumes, allergens or smoking.  Acid reflex, also gastro esophageal reflux disease (GERD) 11/20/2024 65  Cont …d  Chronic sinusitis, bronchitis  Excessive alcohol use  Habitual over use of the voice such as with singers or cheerleaders.  Smoking Less common cause of chronic laryngitis include: ▪ Infections such as TB, syphilis or a fungal infections. ▪ Infections with certain parasites. ▪ Cancer ▪ Vocal cord paralysis, which can result from injury, stroke or a lung tumor or other conditions. 11/20/2024 66  Clinical features  Husky, high pitched voice, Body aches, Fever, Malaise.  Dysphonia (hoarseness) or aphonia (inability to speak)  Dysphagia (difficulty in swallowing)  Dyspnea (difficulty in breathing), predominantly in children  Dry, burning throat, Dry irritating paroxysmal cough.  Cold or flu-like symptoms , Swollen lymph nodes in the throat, chest, or face  Hemoptysis (coughing out blood), Increased production of saliva. Clinical features Cont…d  Signs of acute URTI.  Dry thick sticky secretions.  Dusky red and swollen vocal cords.  congestion of laryngeal mucosa. Treatment SUPPORTIVE  Voice rest.  Steam inhalation.  Cough suppressants.  Avoid smoking and cold climate.  Fluid intake.  Diagnosis  Based upon a combination of a complete history & physical exam.  If symptoms are severe, particularly in children, the doctor may order an x-ray of the neck & chest.  CBC Some times in children rarely in adults. 11/20/2024 70  Laryngoscopy  Visual examination of vocal cords in a procedure called laryngoscopy, by using a light & a tiny mirror to look in to the back of the throat.  Fiber optic -laryngoscopy  Biopsy 11/20/2024 71  Treatment DEFINITIVE  If laryngitis due to gastroesophageal reflux, an H2- inhibitor (ranitidine) or proton-pump inhibitor (omeprazole) is used to reduce gastric acid secretions.  If laryngitis is caused by thermal or chemical burns, steroids are used.  In viral laryngitis, drinking sufficient fluids will be helpful.  If laryngitis is due to a bacterial or fungal infection, appropriate antibiotic or antifungal therapy is given. Supportive Therapy  Drinking lot of fluids - Drink 7-9 glasses of water per day; herbal tea and chicken soup also provides soothing effect.  maintaining good general health - Exercise regularly.  Avoiding smoking - They are bad for the heart, lungs and vocal tract.  Eating a balanced diet - Include vegetables, fruits and whole grain foods.  Avoid dry, artificial interior climates.  Do not eat late at night - may have problems when stomach acid backs up on the vocal cords.  Use a humidifier to assist with hydration. Management of pt with respiratory disorder Oxygen Therapy ❖ Is the administration of oxygen at a concentration greater than that found in the environmental atmosphere ❖ The goal of oxygen therapy is to provide adequate transport of oxygen in the blood while decreasing the work of breathing and reducing stress on the myocardium Indications ❖ Change in the patient’s respiratory rate or pattern( hypoxemia or hypoxia) ❖ Need for oxygen is assessed by arterial blood gas analysis, pulse oximetry, and clinical evaluation. 11/20/2024 74  Oxygen therapy is the administration of oxygen at a concentration greater than that found in the environmental atmosphere.  At sea level, the concentration of oxygen in room air is 21%.  The goal of oxygen therapy is to provide adequate transport of oxygen in the blood while decreasing the work of breathing and reducing stress on the myocardium.  Oxygen transport to the tissues depends on factors such as cardiac output, arterial oxygen content, concentration of hemoglobin, and metabolic requirements.  These factors must be kept in mind when oxygen therapy is considered. 11/20/2024 75  Indications  A change in the patient’s respiratory rate or pattern may be one of the earliest indicators of the need for oxygen therapy.  The change in respiratory rate or pattern may result from hypoxemia or hypoxia.  Hypoxemia - a decrease in the arterial oxygen tension in the blood is manifested by changes in mental status. Such as: ▪ progressing through impaired judgment, ▪ agitation, ▪ 11/20/2024 disorientation, 76  Indications Cont …d  Sign & symptoms of hypoxemia include: ▪ confusion, ▪ lethargy, and coma, ▪ dyspnea, ▪ increase in blood pressure, ▪ changes in heart rate, ▪ dysrhythmias, ▪ central cyanosis (late sign), ▪ diaphoresis, and cool extremities. ▪ Hypoxemia usually leads to hypoxia, which is a decrease in oxygen supply to the tissues. Hypoxia, if severe enough, can be life- threatening. 11/20/2024 77  Indications Cont …d  The signs and symptoms signaling the need for oxygen may depend on how suddenly this need develops.  With rapidly developing hypoxia, changes occur in the central nervous system because the higher neurologic centers are very sensitive to oxygen deprivation.  The clinical picture may resemble that of alcohol intoxication, with the patient exhibiting lack of coordination and impaired judgment. 11/20/2024 78  Indications Cont …d Longstanding hypoxia (as seen in chronic obstructive pulmonary disease [COPD] and chronic heart failure) may produce fatigue, drowsiness, apathy, inattentiveness, and delayed reaction time.  The need for oxygen is assessed by arterial blood gas analysis and pulse oximetry as well as by clinical evaluation. Cautions in Oxygen Therapy As with other medications, the nurse administers oxygen with caution and carefully assesses its effects on each patient. Oxygen is a medication and except in emergency situations is administered only when prescribed by a physician. 11/20/2024 79  Indications Cont …d  In general, patients with respiratory conditions are given oxygen therapy only to raise the arterial oxygen pressure (PaO2) back to the patient’s normal baseline, which may vary from 60 to 95 mm Hg.  In terms of the oxyhemoglobin dissociation curve the blood at these levels is 80% to 98% saturated with oxygen; higher inspired oxygen flow (FiO2) values add no further significant amounts of oxygen to the red blood cells or plasma. 11/20/2024 80  Indications Cont …d Types of Hypoxia: ❑ Hypoxia can occur from either severe pulmonary disease (inadequate oxygen supply) or from extrapulmonary disease (inadequate oxygen delivery) affecting gas exchange at the cellular level. ❑ The four general types of hypoxia are hypoxemic hypoxia, circulatory hypoxia, anemic hypoxia, and histotoxic hypoxia. 11/20/2024 81  Types of Hypoxia Cont …d 1. Hypoxemic Hypoxia Hypoxemic hypoxia is a decreased oxygen level in the blood resulting in decreased oxygen diffusion into the tissues. It may be caused by hypoventilation, high altitudes, ventilation–perfusion mismatch (as in pulmonary embolism), shunts in which the alveoli are collapsed and cannot provide oxygen to the blood (commonly caused by atelectasis), and pulmonary diffusion defects. It is corrected by increasing alveolar ventilation or providing supplemental oxygen 11/20/2024 82  Types of Hypoxia Cont …d 2. Circulatory Hypoxia Circulatory hypoxia is hypoxia resulting from inadequate capillary circulation. It may be caused by decreased cardiac output, local vascular obstruction, low-flow states such as shock, or cardiac arrest. Although tissue partial pressure of oxygen (PO2) is reduced, arterial oxygen (PaO2) remains normal. Circulatory hypoxia is corrected by identifying and treating the underlying cause. 11/20/2024 83  Types of Hypoxia Cont …d ❑ 3. Anemic Hypoxia Anemic hypoxia is a result of decreased effective hemoglobin concentration, which causes a decrease in the oxygen-carrying capacity of the blood. It is rarely accompanied by hypoxemia. ❑ Carbon monoxide poisoning, because it reduces the oxygen-carrying capacity of hemoglobin, produces similar effects but is not strictly anemic hypoxia because hemoglobin levels may be normal 11/20/2024 84  Types of Hypoxia Cont …d 4. Histotoxic Hypoxia Histotoxic hypoxia occurs when a toxic substance, such as cyanide, interferes with the ability of tissues to use available oxygen 11/20/2024 85  OXYGEN TOXICITY  Oxygen toxicity may occur when too high a concentration of oxygen (greater than 50%) is administered for an extended period (longer than 48 hours).  It is caused by overproduction of oxygen free radicals, which are byproducts of cell metabolism.  If oxygen toxicity is untreated, these radicals can severely damage or kill cells. Antioxidants such as vitamin E, vitamin C, and beta- carotene may help defend against oxygen free radicals. (Scanlan, Wilkins & Stoller, 1999). 11/20/2024 86  OXYGEN TOXICITY Cont…d Signs and symptoms of oxygen toxicity include:  substernal discomfort,  paresthesias,  dyspnea,  restlessness,  fatigue,  malaise,  progressive respiratory difficulty, and  alveolar infiltrates evident on chest x-rays. 11/20/2024 87  SUPPRESSION OF VENTILATION  In patients with COPD, the stimulus for respiration is a decrease in blood oxygen rather than an elevation in carbon dioxide levels.  Thus, administration of a high concentration of oxygen removes the respiratory drive.  The resulting decrease in alveolar ventilation can cause a progressive increase in arterial carbon dioxide pressure (PaCO2), ultimately leading to the patient’s death from carbon dioxide narcosis and acidosis.  Oxygen-induced hypoventilation is prevented by administering oxygen at low flow rates (1 to 2 L/min). 11/20/2024 88  OTHER COMPLICATIONS  Because oxygen supports combustion, there is always a danger of fire when it is used. It is important to post “no smoking” signs when oxygen is in use.  Oxygen therapy equipment is also a potential source of bacterial cross-infection; thus, the nurse changes the tubing according to infection control policy and the type of oxygen delivery equipment. 11/20/2024 89  Methods of Oxygen Administration  Oxygen is dispensed from a cylinder or a piped-in system.  A reduction gauge is necessary to reduce the pressure to a working level, and a flow meter regulates the flow of oxygen in liters per minute.  When oxygen is used at high flow rates, it should be moistened by passing it through a humidification system to prevent it from drying the mucous membranes of the respiratory tract. 11/20/2024 90  Methods of Oxygen Administration …  Oxygen delivery systems are classified as low-flow or high-flow delivery systems. 1. Low-flow systems contribute partially to the inspired gas the patient breathes. The amount of inspired oxygen changes as the patient’s breathing changes. Examples of low-flow systems include: 1. nasal cannula, 2. oropharyngeal catheter, 3. simple mask, 4. partial-rebreather and 5. non-rebreather masks. 11/20/2024 91  Methods of Oxygen 2. Administration … High-flow systems provide the total amount of inspired air. ❑ A specific percentage of oxygen is delivered independent of the patient’s breathing. ❑ High-flow systems are indicated for patients who require a constant and precise amount of oxygen. Examples of such systems include: 1. transtracheal catheters, 2. Venturi masks, 3. aerosol masks, 4. tracheostomy collars, 5. T-piece, and 6. face tents 11/20/2024 92  Chest physiotherapy ▪ Includes postural drainage, chest percussion, and vibration, and breathing retraining. The goals of CPT are to remove bronchial secretions, improve ventilation, and increase the efficiency of the respiratory muscles. 11/20/2024 93  Postural drainage Allows the force of gravity to assist in the removal of bronchial secretions. The secretions drain from the affected bronchioles into the bronchi and trachea and are removed by coughing or suctioning. Used to prevent or relieve bronchial obstruction caused by accumulation of secretions. Patient usually sits in an upright position, secretions are likely to accumulate in the lower parts of the lungs. 11/20/2024 94 Positions used for postural drainage 11/20/2024 95  Positions used for postural drainage 11/20/2024 96 Positions used for postural drainage 11/20/2024 97  Nursing Management The nurse should be aware of:- Patient’s diagnosis as well as the lung lobes or segments involved Cardiac status Any structural deformities of the chest wall and spine Auscultating the chest before and after the procedure is used to identify the areas that need drainage and assess the effectiveness of treatment The nurse explores strategies that will enable the patient to assume the indicated positions at home(use of objects readily available at home, such as pillows, cushions, or cardboard boxes 11/20/2024 98  Cont…d PD is usually performed two to four times daily, before meals (to prevent nausea, vomiting, and aspiration) and at bedtime The nurse makes the patient as comfortable as possible in each position and provides an emesis basin, sputum cup, and paper tissues. If the patient cannot cough, the nurse may need to suction the secretions mechanically. 11/20/2024 99  Chest Percussion and Vibration Thick secretions that are difficult to cough up may be loosened. Help dislodge mucus adhering to the bronchioles and bronchi. Percussion is carried out by cupping the hands and lightly striking the chest wall in a rhythmic fashion over the lung segment to be drained. The patient uses diaphragmatic breathing during this procedure to promote relaxation percussion over chest drainage tubes, the sternum, spine, liver, kidneys, spleen, or breasts (in women) is avoided. Percussion is performed cautiously in the elderly (b/c of increase incidence of osteoporosis and risk of rib fracture) 11/20/2024 100  Vibration Is the technique of applying manual compression and tremor to the chest wall during the exhalation phase of respiration ❖Helps increase the velocity of the air expired from the small airways, thus freeing the mucus. ❖After three or four vibrations, the patient is encouraged to cough, contracting the abdominal muscles to increase the effectiveness of the cough 11/20/2024 101 Fig. showing Percussion and vibration. A. Proper hand position for vibration. B. Proper technique for vibration. The wrists and elbows remain stiff; the vibrating motion is produced by the shoulder muscles. C. Proper hand position for percussion. 11/20/2024 102  Nursing Management ❑The nurse ensures that the patient is comfortable, is not wearing restrictive clothing, and has not just eaten. ❑Gives medication for pain, as prescribed, before percussion and vibration and splints any incision and ❑ Provides pillows for support as needed. 11/20/2024 103  Cont …d Deep Breathing and Coughing Effective coughing can keep the airways clear of secretions. An ineffective cough is exhausting and fails to bring up secretions. Instruct the patient to take two or three deep breaths, using the diaphragm. This helps get the air behind the secretions. After the third deep inhalation, tell the patient to hold the breath and cough forcefully. This is repeated as necessary. Good hydration can facilitate this process. 11/20/2024 104  Incentive Spirometry Def:  Incentive spirometry, also referred to as sustained maximal inspiration (SMI).  Incentive Spirometry is designed to mimic natural sighing or vomiting by encouraging the patient to take long, slow, deep breaths.  This is accomplished by using a device that provides patients with visual or other positive feed back when they inhale at a predetermined flow rate or volume & sustain the inflation for at least 5 seconds. 11/20/2024 105 Purpose  To increase tran-pulmonary pressure & inspiratory volumes, improve inspiratory muscle performance, & re- establish or simulate the normal pattern of pulmonary hyperinflation.  When the procedure is repeated on a regular basis, airway patency may be maintained & lung atelectasis prevented & reversed. 11/20/2024 106  Cont …d Indication: Upper abdominal or thoracic- surgery Lower abdominal surgery  Prolonged bed rest  Surgery in patients with COPD  Lack of pain control  Presence of thoracic or abdominal binders. 11/20/2024 107  Using an The inhalation Incentive of air, in a slowSpirometer and controlled manner, helps inflate the lungs.  The marker within the spirometer will measure the depth of each breath.  Assume an upright position if possible (sitting or semi-Fowler’s).  Breathe using your diaphragm.  Place mouthpiece firmly in the mouth, to breathe in deeply and slowly, holding each breath in for 3–4 seconds and exhaling slowly.  Repeat 6–10 times per session.  Use spirometer every hour while awake (keep it within reach).  Try coughing, with splinting of incision, after each use. 11/20/2024 108 Incentive spirometer  How to use an incentive spirometer 11/20/2024 109  ARTIFICIAL AIRWAYS  The patient with an airway disorder such as a laryngeal obstruction or cancer may require the use of a temporary or, in some cases, a permanent artificial airway.  Two types of artificial airways that may be used include an endotracheal tube (ETT) or a tracheostomy tube.  General recommendations are to favor a tracheostomy tube rather than ETT if the patient will be intubated for 21 days or greater, and to favor the ETT over a tracheostomy if support will be required for 10 days or less (Morris et al., 2013). 11/20/2024 110  ARTIFICIAL AIRWAYS Cont…d ETT and tracheostomy tubes have several disadvantages.  The tubes cause discomfort,  the cough reflex is depressed because closure of the glottis is hindered, and  Secretions tend to become thicker because the warming and humidifying effect of the upper respiratory tract has been bypassed. 11/20/2024 111  ARTIFICIAL AIRWAYS Cont…d  The swallowing reflexes are depressed because of prolonged disuse and the mechanical trauma produced by the endotracheal or tracheostomy tube, thus increasing the risk of aspiration.  In addition, ulceration and stricture of the larynx or trachea may develop.  Of great concern to the patient is the inability to talk and to communicate needs. 11/20/2024 112 Endotracheal intubation involves passing an endotracheal tube through the mouth or nose into the trachea. 11/20/2024 113  Cont …d It is a means of providing an airway for patients who cannot maintain an adequate airway on their own Comatose patients, Patients with upper airway obstruction), For patients needing mechanical ventilation, For suctioning secretions from the pulmonary tree 11/20/2024 114  Cont …d Tracheotomy is a surgical procedure in which an opening is made into the trachea. The indwelling tube inserted into the trachea is called a tracheostomy tube It may be either temporary or permanent. Equipment ✓ Sterile gloves ✓ Hydrogen peroxide ✓ Normal saline solution or sterile water ✓ Cotton-tipped applicators ✓ Dressing ✓ Twill tape ✓ Type of tube prescribed, if the tube is to be changed 11/20/2024 115  Cont …d A tracheotomy is used To bypass an upper airway obstruction, To allow removal of tracheobronchial secretions, To permit the long-term use of mechanical ventilation, To prevent aspiration of oral or gastric secretions in the unconscious or paralyzed patient (by closing off the trachea from the esophagus) To replace an endotracheal tube 11/20/2024 116 Tracheostomy tube in place 11/20/2024 117 Tracheostomy tubes. A. Cuffed tracheostomy tube; used for patients on mechanical ventilation. B. Cuffed fenestrated tube; allows the patient to talk. C. Uncuffed tracheostomy tube; not used for adult patients on mechanical ventilation; often used for permanent tracheostomy patients who are not ventilator dependent. 11/20/2024 118  Nursing Management Continuous monitoring and assessment. Newly made opening must be kept patent by proper suctioning of secretions. The patient is placed in a semi-fowler’s position to facilitate ventilation, promote drainage, minimize edema, and prevent strain on the suture lines After the vital signs are stable Analgesia and sedative agents must be administered with caution because of the risk of suppressing the cough reflex. 11/20/2024 119  Preventing Complications Associated With Endotracheal and Tracheostomy Tubes Administer adequate warmed humidity. Maintain cuff pressure at appropriate level. Suction as needed per assessment findings. Maintain skin integrity. Change tape and dressing as needed or per protocol. Auscultate lung sounds. Monitor for signs and symptoms of infection, including temperature and white blood cell count. 11/20/2024 120  Cont …d Administer prescribed oxygen and monitor oxygen saturation. Monitor for cyanosis. Maintain adequate hydration of the patient. Use sterile technique when suctioning and performing tracheostomy care. 11/20/2024 121  Lower Respiratory Tract Disorders 11/20/2024 122  Pneumonia ❖ Pneumonia (from the Greek pneuma, “breath”) is a potentially fatal infection and inflammation of the lower respiratory tract (i.e., bronchioles and alveoli) usually caused by inhaled bacteria and viruses ❖ Is an inflammation of the lung parenchyma. ❖ Is a lung infection involving the lung alveoli (air sacs) and can be caused by microbes, including bacteria, viruses, or fungi.  Pneumonitis -- immune-mediated inflammation of alveoli 11/20/2024 123  Pneumonia Clinical Definition Symptoms of acute LRT infection a) Cough, sputum, chest pain b) Fever,sweating,shiver, aches and pains New focal chest signs on examination OR New radiographic pulmonary infiltrates 11/20/2024 124  Classification of pneumonia Based on causative agent Bacterial or typical pneumonia, Atypical pneumonia Viral pneumonia Fungal pneumonia etc 11/20/2024 125  Pneumonia  Anatomic(morphological) classification Lobar pneumonia- homogeneous consolidation of one or more lung lobes Broncho- pneumonia- multiple patchy shadows in a localized or segmental area. 11/20/2024 126 Bronchopneumonia  Infants + young children and the elderly.  Usually secondary to other conditions associated with local and general defense mechanisms: Viral infections (influenza, measles) Aspiration of food or vomitus Obstruction of a bronchus (foreign body or neoplasm)  Inhalation of irritant gases Major surgery Chronic debilitating diseases, malnutrition 11/20/2024 127  Lobar pneumonia: ⧫ S. pneumoniae. ⧫ Previously healthy individuals. ⧫ Abrupt onset. ⧫ Unilateral stabbing chest pain on inspiration (due to fibrinous pleurisy). 11/20/2024 128  Types of Pneumonia Community-acquired pneumonia(CAP) ⧫ Infection of the pulmonary parenchyma acquired from exposure in the community ⧫ Occurs either in the community setting or within the first 48 hours after hospitalization or institutionalization. ⧫ Infection usually spread by droplet inhalation. ⧫ Highest incidence in winter ⧫ Smoking important risk factor 11/20/2024 129  “Typical” CAP:  History ✓Previously healthy with sudden onset of fever and shortness of breath ✓Presents with “typical” severe, acute infection ✓Infectious agent (usually S. Pneumonia or H. Flu) is culturable/ identifiable ✓Responsive to cell-wall active antibiotics 11/20/2024 130  “Typical” CAP:  Physical signs and symptoms Tachycardia Tachypnea Productive cough with purulent sputum and possible hemoptysis Pallor and cyanosis 11/20/2024 131 Typical CAP---- localized: − dullness to percussion − decreased breath sounds − crackles ,ronchi , egophony Investigations CXR showing lobar consolidation CBC showing leukocytosis w/ left shift Sputum sample contains neutrophil, RBCs; Gram stain may be positive depending on organism 11/20/2024 132 “Atypical” CAP History : Previously healthy present with is usually sub-acute, low-grade fever, sore throat, and intractable cough Minimal sputum production Able to continue to work No sick contacts, recent travel, or evidence of altered immune system 11/20/2024 133 “Atypical” CAP PE reveals a mildly ill-appearing patient with diffuse wheezes on lung exam “Walking pneumonia” syndrome Causative pathogens are difficult to culture/identify by standard methods Not responsive to penicillins 11/20/2024 134  Types Of Atypical Pneumonia.  Mycoplasma pneumonia  Caused by tiny bacteria mycoplasma pneumoniae.  It is generally milder than other types  Children and adults who are infected often show symptoms resembling those of a cold or flu, such as coughing, sneezing, and a mild fever.  Generally, not have to be hospitalized. 11/20/2024 135  Types Of Atypical Pneumonia.  Chlamydophila pneumonia.  Caused by chlamydophila pneumoniae bacteria.  School-age children at greatest risk for this type.  Legionella pneumonia (legionnaires’ disease)  Caused by legionella pneumophila bacteria.  Not spread through person-to-person contact.  Legionnaires’ disease tends to be more serious than other types of atypical pneumonia.  It can lead to respiratory failure and death in some cases. 11/20/2024 136  Common causes Of CAP The causative agents for CAP that requires hospitalization are: ✓ Previously healthy individual: → S. pneumoniae ✓ Pre-existing viral infection → Staph. aureus or S. pneumoniae ✓ Chronic bronchitis → Haemophilus influenzae or S. pneumoniae ✓ AIDS → Pneumocystis carinii, cytomegalovirus, TB ✓ Elderly people and those with co morbid illnesses → H. Influenzae ✓ Legionella, pseudomonas Aeruginosa, and other gram-negative rods. ✓ Viruses (infants and children) ✓ Atypical bacteria 11/20/2024 137 The most common causes for viral pneumonia are: ⚫ Influenza ⚫ Parainfluenza ⚫ Adenovirus ⚫ Respiratory syncytial virus (RSV)  appears mostly in children ⚫ Cytomegalovirus  In immunocompromised hosts 11/20/2024 138 Features of Severe Pneumonia ⧫ ‘Core’ clinical adverse prognostic features (CURB) ⧫Confusion ⧫Urea > 7 mM (>19.1 mg/dL) ⧫Respiration rate >30 /min ⧫Blood Pressure: Systolic BP < 90 mm Hg and/or diastolic BP ≤ 60 mmHg ⧫ NOTE: Patients with 2 or more CURB are at high risk of death 11/20/2024 139  Hospital-Acquired Pneumonia  Also known as nosocomial pneumonia  Is defined as the onset of pneumonia symptoms more than 48 hours after admission in patients with no evidence of infection at the time of admission.  Is an acute lower respiratory tract infection acquired after at least 48 hours of admission to hospital and is not incubating at the time of admission.  Ventilator-associated pneumonia (VAP), is pneumonia occurring more than 48 hours after endotracheal intubation. 11/20/2024 140  Predisposing factors  Defense mechanisms are incompetent or overwhelmed  Decreased cough and epiglottal reflexes (may allow aspiration)  Mucociliary mechanism impaired  Pollution  Cigarette smoking  Upper respiratory infections  Tracheal intubation  Aging  Metabolic disorder  Mechanical ventilation (VAP)  Supine positioning and aspiration  11/20/2024 141  Pneumonia The common organisms responsible for HAP Enterobacter species, Escherichia coli, H. influenzae, Klebsiella species, Proteus, Serratia marcescens, P. aeruginosa, methicillin-sensitive or methicillin-resistant Staphylococcus aureus (MRSA), and S. pneumoniae 11/20/2024 142  Pneumonia Pneumonia in the Immunocompromised Host Includes Pneumocystis pneumonia (PCP), fungal pneumonias, and Mycobacterium tuberculosis. Aspiration Pneumonia Is the pulmonary consequences resulting from entry of endogenous or exogenous substances into the lower airway. 11/20/2024 143  Clinical manifestations ⧫Cough producing greenish or yellow sputum ⧫High fever that may be accompanied by shaking chills ⧫Shortness of breath ⧫Tachypnea ⧫Pleuritic chest pain ⧫ Headache 11/20/2024 144  Clinical manifestations… ⧫ Sweaty and clammy (moist) skin, ⧫ Loss of appetite ⧫ Fatigue ⧫ Blueness of the skin ⧫ Nausea, vomiting ⧫ Mood swings ⧫ Joint pains or muscle aches 11/20/2024 145  Investigations ❖ History ❖ Physical exam ❖ Chest x-ray ❖ Gram stain of sputum ❖ Sputum culture and sensitivity ❖ Pulse oximeter or ABGs ❖ CBC, differential, chemistry ❖ Blood cultures Invasive diagnostic techniques ✓ Transtracheal aspiration ✓ Bronchoscopy with a protected brush catheter ✓ Direct needle aspiration of the lung 11/20/2024 146  Medical management EMPIRIC ANTIBIOTIC THERAPY First line (Mild):Amoxicillin 1g PO TID #5-7days and if penicillin allergy Clarithromycin 250gm PO BID #5-7days (Moderate): Benztylpencillin 1.2g IM QID #7days plus Doxycycline100mg PO BID #7days or Clarithromycin 500gm PO BID #7days If penicillin allergy Cefriaxone 1gm Iv daily #7days plus Doxycycline100mg PO BID #7days or Clarithromycin 500gm PO BID #7days (Severe): Benztylpencillin 1.2g IM every 4hours plus Gentamycin IV daily plus Azithromycin 500mg IV/PO daily If penicillin allergy :Cefriaxone 1gm Iv daily #7days plus Azithromycin 500mg IV/PO daily 11/20/2024 147  Pneumonia cont’d… Medical management… E.g. according to DACA For community acquired ambulatory pts (mild pneumonia):- ◦ Amoxicillin OR ◦ Erythromycin OR ◦ Doxycyciline 11/20/2024 148  Pneumonia cont’d… For community acquired hospitalized pts (severe pneumonia):- Non-Drug treatment: Bed rest Frequent monitoring of temperature, blood pressure and pulse rate. Give attention to fluid and nutritional replacements Administer Oxygen Analgesia for chest pain 11/20/2024 149  Pneumonia cont’d… Drug treatment: Benzyl penicillin PLUS Gentamicin OR Ceftriaxon. Pneumonia due to staphylococcus aureus: Cloxacillin 1-2 gm, IV or IM QID for 10-14 days. 11/20/2024 150  Pneumonia HAP (nosocomial pneumonias) Antimicrobials effective against gram-negative & gram-positive should be given in combination. Suitable combination is: Cloxacillin plus Gentamicin OR Ceftriaxone plus Gentamicin Ciprofloxacin Pneumocytis pneumonia responds to Trimethoprin + Sulfamethoxazole 11/20/2024 151  Chronic Obstructive Pulmonary Disease  COPD is also known as:  Chronic obstructive lung disease (COLD),  Chronic obstructive airway disease (COAD),  Chronic airflow limitation (CAL) and  Chronic obstructive respiratory disease (CORD) 11/20/2024 152  Chronic Obstructive Pulmonary Disease  It is pulmonary disease characterized by airflow limitation that is not fully reversible.  Refers to chronic bronchitis and emphysema, a pair of two commonly co-existing diseases of the lungs in which the airways become narrowed.  This leads to a limitation of the flow of air to and from the lungs causing shortness of breath 11/20/2024 153 ❖ In COPD, less air flows in and out of the airways because of one or more of the following: ❖The airways and air sacs lose their elastic quality. ❖The walls between many of the air sacs are destroyed. ❖The walls of the airways become thick and inflamed. ❖The airways make more mucus than usual, which tends to clog them. 11/20/2024 154 Causes ❖ Smoking ❖ Occupational exposures ❖ Air pollution ❖ sudden airway constriction in response to inhaled irritants, ❖ Bronchial hyperresponsiveness, is a characteristic of asthma. ❖ Genetics-Alpha 1-antitrypsin deficiency 11/20/2024 155 Pathophysiology of COPD Abnormal inflammatory response of the lungs due to toxic gases Response occurs in the airways, parenchyma & pulmonary vasculature. Narrowing of the airway takes place Destruction of parenchyma leads to emphysema. Destruction of lung parenchyma leads to an imbalance of proteinases / antiproteinases. Pulmonary vascularchanges Mucus hyper secretion dysfunction(cilia dysfunction,airflowlimitation,corpulmonale(RVF) 11/20/2024 156  Clinical features ⧫Chronic cough ⧫Sputum production ⧫Wheezing ⧫Chest tightness ⧫Dyspnea on exertion ⧫Wt.loss ⧫Respiratory insufficiency ⧫Respiratory infections ⧫Barrel chest- chronic hyperinflation leads to loss of lung elasticity 11/20/2024 157 DIFFERENTIAL DIAGNOSIS Diagnosis Suggestive feature COPD Onset mid-life Symptom slowly progressive History of tobacco smoking Asthma Onset early in life Symptom varies widely from day to day Symptom worse at night/morning Family history Congestive heart Chest X-ray shows dilated heart, failure pulmonary edema Pulmonary function test shows volume restriction not airway limitation Bronchiectasis Large volume of purulent sputum Commonly associated with bacterial infection Chest x-ray shows bronchial dilation Tuberculosis Onset all ages Chest x-ray shows infiltrate 11/20/2024 158 Microbiological confirmation  Assessment  DX: Spirometry is required to make the diagnosis; the presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation.  According to Modified British Medical Research Council (mMRC) :  mMRC Grade 0:Only get breathlessness with extraneous exercise  mMRC Grade 1: I get short of breath when hurrying the level  mMRC Grade 2:I walk slower than people of the same age the level b/se of breathlessness  mMRC Grade 3: I stop for breath after walking 100m  mMRC Grade 4:I am too breathlessness to leave the house 11/20/2024 159 COPD includes I. Bronchitis II. Emphysema 11/20/2024 160  Bronchitis  Bronchitis is a condition in which the bronchial tubes become inflamed.  Acute (short term) and chronic (ongoing).  Infections or lung irritants cause acute bronchitis.  Chronic bronchitis is an ongoing, serious condition.  It occurs if the lining of the bronchial tubes is constantly irritated and inflamed, causing a long-term cough with mucus. 11/20/2024 161  Chronic bronchitis Presence of recurrent or chronic productive cough for a minimum of 3 months for 2 consecutive years. It is defined as the presence of cough and sputum production for at least 3 months. Risk factors ▪ Bronchial irritants (e.g. cigarette smoke, exposure to pollution) ▪ Genetic predisposition (alpha-1 antitrypsin deficiency) ▪ Respiratory infections 11/20/2024 162  Chronic Bronchitis: Pathophysiology Chronic inflammation Hypertrophy & hyperplasia of bronchial glands that secrete mucus Increase number of goblet cells Cilia are destroyed Bronchial smooth muscle hyper reactivity 11/20/2024 163 Chronic Bronchitis: Pathophysiology Narrowing of airway ⚫ airflow resistance ⚫ work of breathing Hypoventilation & CO2 retention ➔ hypoxemia & hypercapnea 11/20/2024 164 Chronic Bronchitis: Pathophysiology Bronchial walls thickened, bronchial lumen narrowed, and mucus may plug in the airway Alveoli become damaged and fibrosed, Altered function of the alveolar macrophages. The patient becomes more susceptible to respiratory infection. 11/20/2024 165  Chronic Bronchitis: Pathophysiology 11/20/2024 166  Chronic Bronchitis: Pathophysiology Mucus plug Normal lumen 11/20/2024 167 Signs and symptom Acute Chronic  sore throat,  fatigue (tiredness),  coughing,  fever, body aches,  stuffy or runny nose,  wheezing, and  vomiting, and  chest discomfort.  Diarrhea  persistent cough  The coughing may  cough may produce produce large amounts of clear mucus mucus. This type of cough  shortness of breath often is called a smoker's cough. 11/20/2024 168  Diagnosis  History - medical history  Whether you've recently had a cold or the flu  Whether you smoke or spend time around others who smoke  Whether you've been exposed to dust, fumes, vapors, or air pollution –  Mucus -to see whether you have a bacterial infection  chest x ray  lung function tests,  CBC  ABG analysis 11/20/2024 169  MEDICAL MANAGEMENT ⧫ Improve ventilation Broncho dilators like beta2agonists (albuterol) ,anticholinergics(ipratropium bromide- atrovent). Methylxanthines(theophylline,aminophylline) Corticosteroids Oxygen administration ⧫ Remove bronchial secretion ⧫ Promote exercises ⧫ Control complications ⧫ Improve general health 11/20/2024 170  Surgical management  BULLECTOMY Bullae are enlarged airspaces that do not contribute to ventilation but occupy space in the  Lung volume reduction surgery: It involves the removal of a portion of the diseased lung parenchyma.  Lung transplantation 11/20/2024 171  Emphysema ❖ Is a pathologic term that describes an abnormal distention of the airspaces beyond the terminal bronchioles and destruction of the walls of the alveoli. ❖ Is defined as enlargement of the air spaces distal to the terminal bronchioles, with destruction of their walls of the alveoli due to the action of the proteinases.. ❖ As the alveoli are destroyed the alveolar surface area in contact with the capillaries decreases causing formation of dead spaces 11/20/2024 172  Types  The part of the acinus affected determines the subtype. It can be subdivided pathologically into:  Centrilobular (Proximal Acinar)- ⧫The respiratory bronchiole (proximal and central part of the acinus) is expanded. ⧫The distal acinus or alveoli are unchanged. ⧫Occurs more commonly in the upper lobes ⧫is the most common type and is commonly associated with smoking. It can also be seen in coal workers pneumoconiosis. ⧫ 11/20/2024 173 Classification Panacinar- ❑ Is most commonly seen with alpha one antitrypsin deficiency. ❑ The entire respiratory acinus from respiratory bronchiole to alveoli, is expanded. ❑ Occurs more commonly in the lower lobes, especially basal segments, and anterior margins of the lungs. 1. Paraseptal (Distal acinar) -may occur alone or in association with above and the usual association is spontaneous pneumothorax in a young adult. 11/20/2024  174  Emphysema…. 11/20/2024 175  Emphysema…. Clinical ✓Wheezing manifestation ✓Chronic fatigue Early stages ✓Difficult in sleeping ✓ Barell chest ✓Hypoxia ✓ Central cyanosis ✓Polycythemia ✓ Finger clubbing ✓Cough & sputum production ✓ Dyspnea 11/20/2024 176  Clubbing of the Fingers as a Result of Chronic Hypoxia 11/20/2024 177  Emphysema…. Later stages ▪ Hypercapnea ▪ Purse-lip breathing ▪ Use of accessory muscles to breathe ▪ Underweight No appetite & increase breathing workload 11/20/2024 178  Emphysema….. 11/20/2024 179 Emphysema Use accessory muscle Pursed lips breathing 11/20/2024 180 Assessment and Diagnostic Findings History (smoking, occupational exposure) Physical exam PFT Spirometry -to find out airflow obstruction. ABG analysis CT scan of the lung. Screening of alpha antitrypsin deficiency X-ray radiography may aid in the diagnosis. CBC Sputum analysis 11/20/2024 181  Medical Management Risk Reduction (smoking cessation) Pharmacologic Therapy ❖ Bronchodilators Beta2-Adrenergic Agonist Agents:- salbutamol, albuterol Anticholinergic Agents:-Ipratropium bromide Methylxanthines:- aminophylline ,theophylline ❖ Corticosteroids ❖ Other Medications(alpha1-antitrypsin augmentation therapy, antibiotic agents, mucolytic agents, antitussive agents, vasodilators, and narcotics. 11/20/2024 182  Medical Management …….  Oxygen Therapy  Surgical Management  Lung Volume Reduction Surgery  Pulmonary Rehabilitation  Patient Education  Breathing Exercises  Activity Pacing  Self-Care Activities  Nutritional therapy  Coping Measures 11/20/2024 183  Nursing Management  Assessing the Patient  Achieving Airway Clearance  Improving Breathing Patterns  Improving Activity Tolerance  Monitoring and Managing Potential Complications (respiratory insufficiency and failure) 11/20/2024 184 Comparison of emphysema and chronic bronchitis Emphysema Chronic bronchitis Pink Puffers Blue Bloaters Thin Appearance Airway Flow Problem Increased CO2 retention Color is Dusky to Cyanotic Minimal Cyanosis Recurrent Productive Cough Purse Lip Breathing Hypoxia Dyspnea Hypercapnia Hyper-resonance on Chest Respiratory Acidosis Percussion Orthopneic High Hemoglobin Barrel Chest Increased Respiratory Rate Exertional Dyspnea( Early) Dyspnea on Exertion(late) Prolonged Expiratory Time Digital clubbing Speaks in short jerky Cardiac enlargement sentences Anxious Bilateral lower extremity edema  B E 11/20/2024 186  Asthma Asthma is a chronic inflammatory disorder of the airways that is characterized: Clinically by recurrent episodes of wheezing, breathlessness, chest tightness, and cough, particularly at night/early morning. Physiologically by widespread, reversible narrowing of the bronchial airways and a marked increase in bronchial responsiveness to direct or indirect stimuli and with chronic airway inflammation  Is a heterogeneous disease, usually characterized by chronic airway inflammation 11/20/2024 187   The chronic inflammation is associated with airway hyper‐responsiveness that leads to recurrent episodes of wheezing , breathlessness, chest tightness and coughing particularly at night or early morning.  These episodes are usually associated with widespread, but variable airflow obstruction within the lung that is often reversible either spontaneously or with 11/20/2024 treatment 188   Is a chronic inflammatory disease of the airways that causes:- Airway hyperresponsiveness Mucosal edema Mucus production 11/20/2024 189  Asthma classification ❖ Asthma is divided into two main categories, intrinsic and extrinsic. Intrinsic asthma is due to hypersensitivity of the airways independent of antibodies. ❖ These sensitivities can include chemicals, exercise, complement activation, cold air, infection, and emotional stress. ❖ Extrinsic asthma is due to increased levels of IgE in the plasma. 11/20/2024 190 Classification---- 1. Atopic /extrinsic /allergic ( 70%)  Due to increased levels of IgE in the plasma in responses to environmental antigens.  Genetically transmitted  Childhood onset 11/20/2024 191 Classification---- 2. Non-atopic/ intrinsic /non-allergic( 30%) Intrinsic asthma is due to hypersensitivity of the airways independent of antibodies Triggered by non immune stimuli. Patients have negative skin test to common inhalant allergens and normal serum concentrations of ige. Asthma may be triggered by aspirin, pulmonary infections, cold, exercise, psychological stress or inhaled irritants.. 11/20/2024 192 11/20/2024 193  Pathophysiology ❖ Chronic inflammation ❖ Airway Hyperresponsiveness 11/20/2024 194 Pathophysiology of Asthma Non-modifiable Factors: Modifiable Factors: Gender >Environmental Allergens Family History >Emotional factors/Stress >GERD Triggers airway inflammation Release of mast cells, eosinophils, histamine, macrophages, and activated T lymphocytes Increased Goblet cells Acute Bronchoconstriction mucus production Narrowing of the airway passages Cough Difficulty Of Breathing ↓ Oxygenation Wheezing chest Tightness Chest 11/20/2024 195  ETIOLOGY Allergy is the strongest predisposing factor for asthma. Common allergens can be ❖ Seasonal (grass, tree, and weed pollens) or ❖ Perennial (e.g., mold, dust, roaches, animal dander). 11/20/2024 196  ETIOLOGY ❖ Common triggers for asthma symptoms and exacerbations ❖ Airway irritants (e.g., air pollutants, cold, heat, weather changes, strong odors or perfumes, smoke) ❖ Exercise, stress or emotional upset ❖ Rhino sinusitis with postnasal drip ❖ Medications ❖ Viral respiratory tract infections ❖ Gastroesophageal reflux. 11/20/2024 197 Clinical Manifestations The three most common symptoms of asthma are Cough Dyspnea Wheezing As the exacerbation progresses Diaphoresis Tachycardia Hypoxemia and central cyanosis (a late sign of poor oxygenation) 11/20/2024 198  Status Asthmaticus ❖ The severe and prolonged asthma exacerbation with intensive progressive respiratory failure, hypoxemia, hypercapnia, respiratory acidosis, increased blood viscosity and the most important sign is blockade of bronchial b2-receptors. 11/20/2024 199  Status Asthmaticus Stages: 1st - refractory response to b2-agonists (relaxation of the smooth muscles) 2nd - “silent” lung because of severe bronchial obstruction and collapse of small and intermediate bronchi; 3rd stage – the hypercapnic coma. 11/20/2024 200 Asthma…. Assessment and Diagnostic Findings Hx Physical examination Chest X-ray Sputum increase viscosity CBC- eosinophills Lung Function Tests Arterial blood gas analysis and pulse oximetry 11/20/2024 201 Pharmacological Treatment  A stepwise approach is recommended as follows 1. Inhaled salbutamol prn (when necessary) 2. Inhaled salbutamol prn plus low-dose inhaled beclometasone, starting with 100ug twice daily for adults 3. Add low-dose oral theophylline to Step 3 treatment (assuming long-acting beta agonists and leukotriene antagonists are not available) 4. Add oral prednisolone, but in the lowest dose possible to control symptoms (nearly always less than 10mg daily) 11/20/2024 202  REFER The patient should be referred in the following conditions:  When asthma is poorly controlled  When the diagnosis of asthma is uncertain  When regular oral prednisolone is required to maintain control  5. FOLLOW UP  Patient and family education should be provided  Advise the patient to carry the device always  Emphasize the need for adherence to drugs.  Advice regarding dealing with triggers  11/20/2024 203  Asthma cont’d… Medical management There are two general classes of asthma medications: Quick-relief medications for immediate treatment of asthma symptoms and exacerbations. Long acting medications to achieve and maintain control of persistent asthma. 11/20/2024 204  Asthma cont’d… According to DACA: Initial treatment ✓ Salbutamol (metered dose inhaler MDI). Alternatives ✓ Aminophylline, 5mg/kg by slow I.V. push over 5 minutes. OR ✓ Adrenaline, 0.5ml sc. 11/20/2024 205  Asthma cont’d… Maintenance therapy for chronic asthma in adults: ❖ Requires prolonged use of anti-inflammatory drugs mainly in the form of steroid inhalers Intermittent asthma: ▪ Salbutamol, inhaler 200 microgram/puff,1-2 puffs to be taken as needed but not more than 3-4 times a day Alternative ▪ Ephedrine + Theophylline 11/20/2024 206  Asthma cont’d… Persistent mild asthma ✓ Salbutamol, inhaler, 200 micro gram/puff 1-2 puffs to be taken, as needed but not more than 3-4 times/day PLUS ✓ Beclomethasone, oral inhalation 1000mcg QD for two weeks Alternative ✓ Ephedrine + Theophylline (11mg + 120mg), P.O. two to three times a day PLUS ✓ Beclomethasone oral inhalation 1000mcg QD for two weeks. 11/20/2024 207  Asthma cont’d… Persistent moderate asthma Salbutamol, inhalation 200microgram/puff 1-2 puffs as needed PRN not more than 3-4 times a day. PLUS Beclomethasone, 2000mcg, oral inhalation QD for two weeks and reduce to 1000 mcg if symptoms improve. 11/20/2024 208  ACUTE EXACERBATION OF ASTHMA  The following patients have a high risk of future exacerbations and may have a poor asthma outcome.  Risks for exacerbation  Uncontrolled asthma symptoms  One or more severe exacerbation in previous year  Start of the patient’s usual ‘flare-up’ season  Exposures: tobacco smoke; indoor or outdoor air pollution; indoor allergens  Major psychological or socio-economic problems for child or family Poor adherence with controller medication, or incorrect inhaler technique 11/20/2024 209  Management of Asthma exacerbation  Prednisolone 30–40mg for five days for adults and 1mg per kg for three days for children, or longer, if necessary, until they have recovered;  Salbutamol in high doses by metered dose inhaler and spacer (e.g. four puffs every 20 minutes for one hour) or by nebulizer;  Oxygen , if available, if O2 saturation levels are below 90%) 11/20/2024 210  Asthma cont’d… Severe persistent asthma ✓ Salbutamol, inhalation , 200 micro gram/puff 1-2 puffs not more than 3-4 times a day PLUS ✓ Beclomethasone, 2000 mcg, oral inhalation daily 11/20/2024 211  Asthma…. Nursing management ❖ Assessing patients respiratory status ❖ The purpose and action of each medication Triggers to avoid, and how to do so ❖ Proper inhalation technique 11/20/2024 212  Asthma…. Complications Status asthmaticus Respiratory failure Pneumonia Atelectasis 11/20/2024 213  Bronchiectasis Is a chronic, irreversible dilation of the bronchi and bronchioles. Bronchiectasis is a chronic respiratory disease characterized by a syndrome of productive cough and recurrent respiratory infections due to permanent dilatation of the bronchi. Bronchiectasis represents the final common pathway of different disorders, some of which may require specific treatment. 11/20/2024 214 Cont …d Bronchiectasis may be caused :- Airway obstruction Diffuse airway injury Pulmonary infections and obstruction of the bronchus or complications of long-term pulmonary infections 11/20/2024 215 Cont …d Genetic disorders such as cystic fibrosis Abnormal host defense (eg, ciliary dyskinesia or humoral immunodeficiency) Idiopathic causes 11/20/2024 216 11/20/2024 217 Etiology ❖ Congenital causes (e.g. Mounier-Kuhn syndrome) ❖ COPD, and smoking ❖ Cystic fibrosis ❖ Mucociliary dysfunction (e.g. primary ciliary dyskinesia) ❖ Primary or secondary immune deficiency ❖ Pulmonary fibrosis and pneumoconiosis 11/20/2024 218 Etiology ❖ Post obstruction (e.g. with a foreign body) ❖ Post infection (e.g. TB, recurrent pneumonia) ❖ Recurrent small volume aspiration ❖ Allergic bronchopulmonary aspergillosis ❖ Systemic inflammatory diseases (eg. rheumatoid arthritis, sarcoidosis) 11/20/2024 219 Features suggest Bronchiectasis ❖ Diagnosis of asthma that is unresponsive to usual management ❖ Digital clubbing (this is rare in COPD and asthma) ❖ Lack of a significant smoking history (less than an average of 20 cigarettes per day for 10 years) in a person with suspected COPD ❖ History of recurrent and/or severe pneumonia including tuberculosis 11/20/2024 220 Features suggest Bronchiectasis ❖ Presence of ‘unusual organisms’ in sputum (e.g. Aspergillus, atypical/nontuberculous mycobacterium, Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae) ❖ Childhood associated with significant environmental and social disadvantage 11/20/2024 221  Clinical Manifestations Chief complaints are: Chronic cough, Purulent sputum(Copious and purulent and pools in the dilated airways). Dyspnea and Sometimes haemoptysis Clubbing of the fingers also is common because of respiratory insufficiency. Wheezes and crackles 11/20/2024 Repeated episodes of pulmonary infection 222  Diagnostic tests ❖ History ❖ Sputum culture ❖ The chest CT is the golden standard diagnostic tool for Bronchiectasis with the typical presentation of bronchial diameter larger than nearby pulmonary artery without normal bronchial tapering. 11/20/2024 223 Medical management Antibiotics may be used intermittently or for prolonged periods. Bronchodilators improve airway obstruction. Mucolytic agents help thin secretions Chest physiotherapy helps mobilize secretions Oxygen is used if hypoxemia is present 11/20/2024 224 Nursing management Encourage to stop smoking & other factors that increase the production of mucus Teaching the patient and family How to perform postural drainage Assess patients’ nutritional status/appetite Teach the patient about early signs of respiratory infection and the progression of the disorder. 11/20/2024 225