Lower Airway Disorders Study Guide PDF

**Lower Airway Disorders** **1. Acute Bronchitis** - **Etiology/Pathophysiology:** - Usually secondary to an Upper Respiratory Infection (URI) - May be related to inhaled irritants - Inflammation of mucous membranes of major bronchi and their branches, resulting in t...

**Lower Airway Disorders** **1. Acute Bronchitis** - **Etiology/Pathophysiology:** - Usually secondary to an Upper Respiratory Infection (URI) - May be related to inhaled irritants - Inflammation of mucous membranes of major bronchi and their branches, resulting in tenacious secretions that can become a culture medium for bacteria - **Clinical Manifestations:** - **Productive cough** - Low-grade fever - Diffuse rhonchi and wheezes - Dyspnea and chest pain - Generalized malaise and headache - **Assessment:** - Subjective: Ask about headache, body aches and chest tightness - Objective: - Frequent vital sign assessment - Auscultate breath sounds, noting rhonchi, wheezing, or basilar crackles - **Diagnostic Tests:** - Chest x-ray to view lung fields - Sputum culture to determine bacterial infection - **Medical Management:** - Aimed at quick recovery to prevent secondary infection - **Bronchodilators** (e.g., albuterol) - **Antibiotics** for active infection or prophylaxis (e.g., ampicillin) - **Cough suppressants**: opioid (codeine) or non-opioid (dextromethorphan) - **Antipyretics** (e.g., Tylenol) - **Nursing Interventions:** - Facilitate recovery and prevent secondary infections - **Assess for signs and symptoms of infection**: fever, dyspnea, mucopurulent sputum, amount of sputum - Administer antipyretics and antibiotics as ordered - **Assess ability to move secretions and note any increase in retained secretions** - Facilitate airway clearance by elevating head of bed and liquefying secretions with a humidifier and adequate fluid intake (3000-4000 mL/day) - Suction as needed - Avoid dairy products when offering fluids - **Patient Teaching:** - Prevent exacerbations or recurrence of infections - Increase fluid intake - Incorporate rest periods - Recognize worsening symptoms (purulent sputum, dyspnea) - Use analgesics and antipyretics - Avoid irritants - **Prognosis:** Good **2. Legionnaires' Disease** - **Etiology/Pathophysiology:** - Caused by *Legionella pneumophila* - Gram-negative aerobic bacillus that thrives in water reservoirs - Transmitted via airborne route - Presents in two forms: influenza or Legionnaire's disease - Legionnaire\'s disease results in life-threatening pneumonia with lung consolidation and alveolar necrosis - Can progress in less than a week, leading to respiratory and renal failure, bacteremia shock, and death - **Clinical Manifestations:** - Significantly elevated temperature - Headache - Nonproductive cough - Diarrhea - General malaise - **Assessment:** - Subjective: Note complaints of dyspnea, headache, and chest pain on inspiration - Objective: - Significantly elevated temperature (102-105°F or 38.8-40.5°C) - Non-productive cough with difficult and rapid breathing - Crackles and wheezing on auscultation - Signs of shock (tachycardia and hypotension) - Hematuria indicating renal impairment - **Diagnostic Tests:** - Urine testing to confirm diagnosis - Cultures of blood, sputum, and pulmonary tissue/fluid to confirm presence of *L. Pneumophila* - Chest x-ray: patchy infiltrates and small pleural effusions - **Medical Management:** - Close observation for disease progression - Possible mechanical ventilation for respiratory support - Temporary renal dialysis due to acute kidney failure - IV therapy for fluid and electrolyte replacement - Oxygen therapy - **Medications**: - Antibiotics (e.g., erythromycin IV early, then oral) - Rifampin - Antipyretics for hyperthermia - Vasopressors (dopamine or dobutamine) and/or inotropes (for cardiac output and shock) - Analgesics to promote comfort - **Nursing Interventions:** - Maintain bed rest; monitor I&Os - Monitor for impending shock: decreased blood pressure and increased pulse - Administer vasopressor drugs as ordered - Maintain hydration status and urinary output - Assess changes in level of consciousness - Assist with acute hemodialysis if indicated - Assess for respiratory failure - Note respiratory rate, rhythm, and effort - Be alert for cyanosis and dyspnea - Assist with oxygen therapy or mechanical ventilation - Facilitate ventilation; semi-Fowler\'s position if tolerated; suction as needed - Have patient cough and deep breathe q 2 hr if able - Identify associated factors, such as ineffective airway clearance, pain, and altered level of consciousness **3. Severe Acute Respiratory Syndrome (SARS)** - **Etiology and Pathology:** - Infection caused by a coronavirus - Spreads through close contact (likely via respiratory droplets) and possibly by touching contaminated objects - **Clinical Manifestations:** - Fever greater than 100.4°F (38°C) - Headache - Discomfort and muscle aches - Dry cough and shortness of breath (after 2-7 days) - **Diagnostic Tests:** - Chest radiograph - Nasopharyngeal and oropharyngeal swabs - Bronchoalveolar lavage - White blood cell count - **Medical Management:** - Respiratory isolation, including use of a particulate respirator mask - Antiviral medications (e.g., ribavirin) and corticosteroids may be given - **Antibiotics are not effective against the virus but may be used for secondary bacterial infections** - **Nursing Interventions:** - Notify local public health department - Respiratory isolation and meticulous hand hygiene to prevent spread - Discharge home when respiratory status returns to baseline (10 days after fever resolves and symptoms improve) **4. Anthrax** - **Etiology/Pathophysiology:** - Caused by *Bacillus anthracis* (gram-positive aerobe) - Most commonly infects hoofed animals - Spread through direct contact with bacteria and spores; dormant spores become active in a living host - Spores enter via skin, intestines, or lungs - Not normally person-to-person, but contact with infected tissue is contagious - Three types: - Cutaneous: most common; enters through skin cut or abrasion, forming a black eschar. Typically not fatal with antibiotics - Gastrointestinal: least common; from ingesting contaminated food, causing ulcers. Can cause death from sepsis if not treated early - Inhalation: most deadly; spores inhaled into lungs - **Clinical Manifestations:** - Inhalational anthrax: initial symptoms like a cold or influenza, but without nasal secretions - Subsequent breathing problems, hemorrhage, tissue necrosis, and lymph edema - Death usually from blood loss and shock - **Diagnostic Tests:** - Chest x-ray to differentiate from pneumonia (widened mediastinum is characteristic of inhalational anthrax) - Culture specimen from vesicular fluid for cutaneous anthrax - Stool specimen for culture if intestinal anthrax is suspected - **Medical Management:** - **Antibiotic therapy for all cases** - Ciprofloxacin (Cipro) is the treatment of choice due to possible resistance to other antibiotics - 60 day course of therapy recommended - Alternative therapy of 30 days of antibiotics and 3 doses of anthrax vaccine **5. Tuberculosis (TB)** - **Etiology/Pathophysiology:** - Chronic pulmonary and extrapulmonary infectious disease - Acquired by inhaling a dried droplet nucleus containing *Mycobacterium tuberculosis* - Most commonly affects the lungs, but can affect other areas - Macrophages ingest TB bacteria, which form hard capsules called tubercles. TB can remain dormant for many years - **Infection vs. Active Disease:** - Infection precedes active disease; only 10% of infections progress - **Infection**: presence of mycobacteria, no symptoms, demonstrates antibodies (+PPD), negative chest x-ray (latent TB) - **Disease**: pathologic signs and symptoms indicating mycobacteria activity; positive skin test, positive chest x-ray, positive sputum or gastric contents for AFB - Predisposing factors: compromised immune system, close contact, low-income populations, health care workers, those born in high prevalence countries, residents of long term care, and the elderly - **Clinical Manifestations:** - May have no symptoms, or they may develop insidiously - Early symptoms: anorexia/weight loss, productive cough, fever, weakness - Later symptoms: recurring fever with chills, night sweats, hemoptysis - **Assessment:** - Subjective: note reports of loss of muscle strength and weight loss - Objective: evaluate and report characteristics of sputum (amount, color, blood) - **Diagnostic Tests:** - **Mantoux tuberculin skin test (PPD)**: read 48-72 hours later, measure induration - Negative reaction: less than 5mm - A positive TB test indicates antibodies are present, not necessarily active TB - Sputum culture for acid-fast bacillus (AFB) to confirm active TB - Three positive acid-fast smears indicate a presumptive diagnosis - Diagnosis is confirmed with tubercle bacilli growth in culture (6-8 weeks) - QuantiFeron-TB Gold Test: more specific than PPD with results 24 hours after collection - All patients with TB must be reported to public health authority - **Medical Management:** - Isolation: AFB isolation during hospital stay - Negative pressure ventilation room, particulate matter mask - Patients wear a mask when leaving room - Infants/children do not generally require isolation - **Medications**: drug therapy for active TB - Treatment is lengthy (6-9 months or longer), combination of medications - Common medications include isoniazid, rifampin, and pyrazinamide, streptomycin or ethambutol - Pyrazinamide is associated with uric acid elevations - **Nursing Interventions:** - Implement isolation measures for suspected TB - Negative pressure room - Patients cover their nose and mouth when coughing or sneezing - Focus on preventing complications and illness transmission - Monitor for dyspnea or signs and symptoms of pneumothorax - Evaluate respiratory effort and assist as needed - Assess sputum for hemoptysis - Help immobile patient to turn, cough, and deep breathe q 2--4 hr to prevent pooling of secretions - Obtain specimen for culture (proper collection and handling) - Employ AFB isolation until therapy is initiated successfully - Employ drainage and secretion precautions until wounds from patient with extrapulmonary TB stop draining - Instruct patient to cough and sneeze into tissue and properly dispose of it **6. Pneumonia** - **Etiology/Pathophysiology:** - Inflammatory process of respiratory bronchioles and alveolar spaces caused by infection, irritation, aspiration, over-sedation, and inadequate ventilation - Can occur any season but most common during winter and spring - More common in infants and older adults - Susceptible patients: damaged respiratory defense mechanisms, diseases affecting antibody response, alcoholics, delayed WBC reaction - Mode of transmission depends on the infecting organism - Classified by organism - **Causes**: - Bacterial pneumonia: alveolar pus formation with consolidation (Streptococcus pneumoniae, Hemolytic strep type A, Staphylococcus aureus, Haemophilus influenza type B, and Legionella pneumophila are listed) - Nonbacterial or atypical: Mycoplasma, Legionella pneumophila, Pneumocystis jiroveci - Aspiration pneumonia: foreign or toxic material, often during altered LOC (Staphylococcus aureus, Escherichia coli, Klebsiella, Pseudomonas, and Proteus species are listed as causes) - Viral pneumonia: interstitial inflammation without consolidation or exudates (mycoplasma included here) - Fungal/mycobacterial pneumonia: patchy distribution with necrosis and cavities - Chemical: presentation depends on pH - **Clinical Manifestations**: - Sudden onset of sharp chest pain (pleurisy) - Severe chills - Elevated temperature and night sweats - Painful, productive cough (often purulent) - Streptococcal/pneumococcal: rust color - Staphylococcal: salmon color - Haemophilus: yellow/green color - Viral: mucopurulent or blood-tinged - Increased heart rate - Tachypnea with dyspneic expiration - **Assessment:** - Patient history and physical exam - Subjective: Description of onset, duration, and history of cough, fever, and night sweats - Objective: - Level of consciousness - Vital signs every two hours (especially temperature and respirations) - Monitor color, consistency, and amount of sputum - Observe respiratory effort and difficulty with breathing - Auscultate for inspiratory crackles or localized absent breath sounds - **Diagnostic Tests:** - Blood and sputum cultures to identify organism (sputum culture before antibiotics) - Chest x-ray reveals changes in density (lower lobes) - WBC elevated in bacterial, decreased in viral/mycoplasma - Pulmonary function test to determine if lung volume is decreased - ABG to identify altered gas exchange - Oximetry for rapid and continuous oxygen assessment - **Medical Management:** - **Medications**: - Antibiotic therapy (penicillin, erythromycin, cephalosporin, and tetracycline) - Antibiotics not effective in viral pneumonias - Oxygen therapy - Analgesics/antipyretics - Expectorants - Bronchodilators - Vaccine available for streptococcal pneumonia - Indicated for those with chronic illness, recovering from serious illness, older than 65, or in long-term care facilities - Physiotherapy: chest percussion and postural drainage, encourage cough, deep breathing, incentive spirometry, and ambulation to mobilize secretions - Humidification with humidifier or nebulizer for tenacious secretions - Chest tube for pus in pleural space (empyema) - **Nursing Interventions:** - Assess ventilation: rate, rhythm, depth; chest expansion; and respiratory distress - Auscultate lungs for crackles, wheezes, and pleural friction rub - Identify contributing factors such as airway clearance or obstruction problems or weakness - Encourage increased fluid intake to 3 L/day to liquefy secretions - Maintain patient in semi-Fowler's or sitting and leaning forward - Assess for signs of hypoxemia (restlessness, disorientation, and irritability) - Administer oxygen to maintain saturations above 90% - Monitor body temperature - Provide hydration to liquefy secretions and replace fluids. Fluid intake of at least 3 L/day, individualized for patients with heart failure - An intake of at least 1500 calories/day - **Patient Teaching:** - Deep-breathing and coughing techniques and the use of an incentive spirometer - Handwashing - Prescribed medications (purpose, action, dosage, frequency, side effects) - Specific type of pneumonia, treatment, anticipated response, possible complications, and probable disease duration - Importance of consuming large quantities of fluid; except in patients with pulmonary edema, congestive heart failure, and/or renal failure - Adaptive exercise and rest techniques - Availability of pneumococcal vaccine - Report changes in sputum, decreased activity tolerance, fever despite antibiotics, increasing chest pain, or a feeling that things are not getting better - **Prognosis:** - Usually improves in 2-3 days and resolves within 2-3 weeks with proper treatment - Major cause of disease and death in critically ill patients - Pneumonia and influenza remain a leading cause of death in the US - Bacterial aspiration pneumonia carries a poor prognosis **7. Pleurisy** - **Etiology/Pathophysiology:** - Inflammation of the visceral and parietal pleura - Causes: bacterial or viral infection, spontaneous, complication of pneumonia, TB, pleural trauma, pulmonary infarction, lung cancer, viral infections of intercostal muscles - **Clinical Manifestations:** - Sharp inspiratory pain, radiating to shoulder or abdomen of the affected side - Fever and dry cough if pleural effusion develops (pain will diminish) - Dyspnea - Elevated temperature - **Assessment:** - Subjective: patient complaint of chest pain on inspiration, elevated temperature - Objective: - Assess the nature of inspiratory pain, including radiation - Frequent vital signs, including temperature - Respiratory rate and rhythm, noting dyspnea - Auscultate for pleural friction rub - **Diagnostic Tests:** - Pleural friction rub may be considered diagnostic - Chest x-ray of limited value unless pleural effusion is present - **Medical Management:** - **Medications**: - Analgesics (Demerol or morphine) and antipyretics (Tylenol) - Antibiotics for the underlying cause (e.g., penicillin) - Oxygen therapy for inadequate gas exchange - Anesthetic block of intercostal nerves - **Nursing Interventions:** - Assess for pain - Administer medications as ordered and assess effectiveness - Provide non-pharmacologic comfort measures - Encourage lying on the affected side to splint the chest wall - Position the patient comfortably on the affected side and apply heat to the area - Assess LOC, noting any increase in restlessness or disorientation - Auscultate lungs for wheezes, crackles, and pleural friction rub - Teach patient to cough and deep breathe every 2 hours and to splint rib cage when coughing - Heat may be applied to the affected side - Elevate head of bed - Reposition patient every two hours **8. Pleural Effusion/Empyema** - **Etiology/Pathophysiology:** - Fluid accumulation in the pleural space, may or may not be infected - Rarely primary but occurs when the physiologic pressure in the lungs and pleurae is disturbed (Pancreatitis, cirrhosis of the liver and heart failure are common causes) - When the fluid is infected, it is called empyema (Usually bacterial associated with pneumonia, TB and blunt chest trauma) - May be acute or chronic - If untreated, pleura may become scarred and fibrosed, losing elasticity - **Clinical Manifestations:** - Generally associated with other disease processes - Persistent fever despite antibiotics - **Assessment:** - Subjective: Assess dyspnea, air hunger, fear, and anxiety related to decreased oxygen level - Objective: - Signs and symptoms of respiratory distress (nasal flaring, tachypnea, dyspnea) - Decreased breath sounds, dry cough - Frequent vital signs, especially temperature - **Diagnostic Tests:** - CXR to visualize effusions - Thoracentesis to obtain specimen for culture and for symptomatic treatment of dyspnea - **Medical Management:** - Thoracentesis to remove fluid from the pleural space (less than 1300-1500 mL at a time) - Chest tube placement for continuous drainage - Re-establishes negative pressure in the pleural cavity - **Prognosis:** Variable, depending on the patient\'s overall health status **9. Chest Tube Management** - **Chest Tubes and Drainage System:** - Inserted for continuous drainage of fluid, blood, or air from the pleural cavity, and for medication instillation - Sutured in place and covered with a sterile dressing - Closed drainage system maintains negative pressure - Intrapleural pressure is below atmospheric pressure (4 to 5 cm H2O below during expiration, 8 to 10 cm H2O below during inspiration) - Lungs will collapse if intrapleural pressure equals atmospheric pressure - One or two thoracotomy tubes are inserted - Anterior tube removes air from the pleural space - Posterior tube drains serosanguineous fluid or purulent exudate - Posterior tube is often larger to prevent occlusion - Connected to a pleural drainage system with a water-seal to reestablish negative pressure - Suction may be applied to the drainage system - **Nursing Interventions and Patient Teaching:** - Bed rest - Frequent oral care - Encourage effective cough and deep breathing - Apply a large sterile dressing after thoracentesis and assess for drainage - Ensure patency of the chest tube system - **Areas of Concern**: - Ensure water in the water-seal chamber fluctuates when suction is applied - No bubbling in the water seal (indicates an air leak) - Assess for increased dyspnea and check chest x-rays for lung consolidation - Note air leaks, and ensure tubing is secure and patent - Monitor white blood cells, temperature, and presence of purulent drainage (infection) - Position the patient on the unaffected side (but patient may be in any position of comfort as long as the water-seal remains below the chest) - Never elevate the drainage system to the level of the patient's chest - Facilitate coughing and deep-breathing at least every 2 hours and auscultate breath sounds frequently - Document amount and characteristics of pleural fluid drainage - Prevent accidental removal by securing connections - Keep tubing straight and loosely coiled - Do not let the patient lie on it; tubing should never be over side rails - Administer antibiotics as ordered **10. Atelectasis** - **Etiology/Pathophysiology:** - Common postoperative complication from a mucous plug (shallow breathing, interferes with effective coughing) - Collapse of alveoli in the lung due to blockage or poor inflation - May be limited or larger areas of the lung - Prevents the exchange of carbon dioxide and oxygen - **Causes**: - Ineffective clearance of secretions due to shallow breathing (hypoventilation) - Mucous accumulation - Prolonged bed rest and hypoventilation - Aspiration of food or vomitus - Compression in lung tissue by tumors - Hypoventilation causes all or part of the lung to collapse - Mucous accumulation leads to bronchial obstruction - Can lead to stasis pneumonia because the retained secretions can lead to bacterial growth - **Clinical Manifestations:** - Tachypnea - Fever - Pleural friction rub - Restlessness - Hypertension - **Assessment:** - Subjective: shortness of breath, air hunger, anxiety, and fatigue - Objective: - Decreased breath sounds and crackles - Tachycardia & hypertension initially, followed by bradycardia & hypotension - Monitor respiratory rate and effort - Assess for altered LOC due to hypoxia - **Diagnostic Tests:** - Serial chest x-ray reveals atelectatic changes - Chest CT scan can detect compression and may reveal the underlying condition - ABG may reveal PaO2 less than 80mmHg; pulse oximetry may reveal oxygen saturation less than 90% - Bronchoscopy may reveal a bronchial obstruction - **Medical Management:** - Requires chest tube insertion to re-expand lung - Instruct to deep breath and cough - Incentive spirometry 10 times/hr - May require intubation with mechanical ventilation - May require suctioning, coughing, and vigorous respiratory therapy - **Medications**: bronchodilators, antibiotics, and mucolytic agents - A bronchoscope can be used to remove thick secretions or mucous plug - **Nursing Interventions:** - Improve ventilation, focus on prevention - Assess ability to move secretions - Humidify air and bronchodilators to loosen secretions - Incentive spirometry, deep breathing and coughing - Encourage adequate hydration - Auscultate breath sounds - Assess color, amount, and consistency of sputum - Chest physiotherapy with postural drainage - Identify patient's emotional support system - Assess patient's ability to comply with prescribed regimen