Respiratory Infectious Diseases PDF 2022

MED SURG CARE OF CLIENTS WITH ALTERED AIRWAY FUNCTION II REFERENCE: DeWit and Stromberg: Chapters 12 & 14 I. Respiratory Infectious Diseases A. Acute Bronchitis 1. often extension of upper airway infection; usually vir...

MED SURG CARE OF CLIENTS WITH ALTERED AIRWAY FUNCTION II REFERENCE: DeWit and Stromberg: Chapters 12 & 14 I. Respiratory Infectious Diseases A. Acute Bronchitis 1. often extension of upper airway infection; usually viral; bronchi are inflamed (so deeper in chest infection) 2. other causes: inhalation of dust, auto exhaust, pollution, tobacco smoke 3. early symptoms similar to common cold: productive cough, sore throat, runny/stuffy nose, headache, arthralgia (pain in the joints), fatigue 4. symptomatic treatment: humidification, cough suppressant (do not drink fluid immediately afterwards), bronchodilator med (ends in ‘erol’), fluids, rest, antibiotics (if sputum is positive for bacteria) B. Influenza 1. Etiology a. acute, highly infectious disease affecting upper and lower respiratory tracts b. 9 – 36 million cases per year/12,000 – 56,000 deaths/year c. 4 major types 1. A and B – responsible for seasonal epidemics each year 2. C – causes mild respiratory illness and no epidemics 3. D affects cattle d. spread by direct and indirect contact – touching (direct), talking, coughing, sneezing (indirect) - remain 3 ft 2. Pathophysiology a. affects mucous membranes of respiratory system causing inflammation and tissue destruction b. inflammation affects the lungs, pharynx, sinuses, estenic tube c. tissue destruction creates an environment for bacteria to grow and cause secondary infection; influenza on it’s on is classified as viral but can lead to bacteria infection 3. Signs and Symptoms a. usually 2-3 days after exposure; headache, fever (101-103), chills, arthralgia, sore throat, hacking cough, runny nose, nasal congestion, sensitivity to light (photophobia-light is painful), N, V, D 4. Diagnosis a. based on signs and symptoms, viral culture, serology, rapid molecular assays, or rapid influenza diagnostic tests (RIDTs) – usually only test when results will alter treatment decisions 5. Treatment a. antibiotics only if there is evidence of secondary bacteria infection b. antivirals are possible if high risk – Flumadine, Relenza, Tamiflu – -must start within 48 hours of onset c. uncomplicated is treated symptomatically- analgesics, saline gargles, cough suppressant, antipyretics, humidification, rest, increase fluid intake to 3000 ml/day MS-RESP #2 OUTLINE-2022 1 OF 13  C. Pneumonia 1. Etiology and Pathophysiology a. extensive inflammation of the lung resulting in consolidation of lung tissue as it fills with exudate or interstitial inflammation and edema b. can affect: 1 (most common) or both c. bacterial pneumonia is more common but it can also be viral (which is less severe usually); bacterial pneumonia is caused by bacteria pneumococcus d. pathogens always present in upper respiratory tract (because it is exposed to environment) e. can occur when resistance is lowered d/t chronic disease, alcoholism, dability (to be in poor physical condition), very old or very young f. also caused by inhalation of irritant, aspiration or inactivity (hypostatic) g. fungal – in immunocompromised pt’s (HVI, AIDs) 2. Prevention a. People over 65 or chronic respiratory disease – (COPD) should get a pneumonia vaccine every 5 years b. frequent turning, coughing and deep breathing (post op) c. side lying if post op recovery for anesthesia- helps prevent aspiration d. elevate HOB at least 45 degrees if risk for aspiration or tube feed e. health care associated pneumonia 1. hospital acquired pneumonia- occurs more than 48 hours after admission 2. ventilator-associated pneumonia- occurs 48-72 hours after endotracheal intubation 3. Signs and Symptoms: high fever w/ chills, productive cough, sputum is rusty or blood flecked, sweating, chest pain, malaise, arthralgia 4. Diagnosis- chest x-ray, CBC, sputum C&S 5. Treatment- antibiotics (goal is to get the 1st dose of antibiotics within the 1st 4 hrs - better outcomes if treated more quickly)(can be IV or oral), antivirals (if caused by virus), antifungals (if caused by fungus), cough and deep breath, increase fluid, protein and vit c in diet, rest, antipyretics, analgesics D. Atelectasis 1. collapsed alveoli 2. causes – decreased surfactant(fat molecule that prevent alveoli from collapsing), bronchial obstruction, anesthesia, surgical pain, positioning during surgery 3. usually reversible 4. diminished breath sounds are expected 5. prevent by cough and deep breathing, incentive spirometer, repositioning E. Tuberculosis 1. Etiology a. characterized by lesions within the lung tissue that can become necrotic and die OR can heal by fibrosis and becomes hard and calcifies b. caused by Mycobacterium tuberculosis (acid-fast bacillus) c. latent TB infection - do not have any active s/s but can become active whenever immune system is weakened d. spread via contaminated airborne droplets that can stay suspended in the air for several hours MS-RESP #2 OUTLINE-2022 2 OF 13  e. infection usually occurs with prolonged exposure f. third leading infectious cause of death worldwide 2. Pathophysiology a. bacillus enters lungs causing local inflammatory reaction b. 2 to 12 weeks before detected by TB skin test c. if exposure suspected, 2nd skin test 8 to 10 weeks later d. granuloma at site of inflammation, bacillus walls off forming a tubercle – caseous necrosis (core of cheese like material) develops in the center of the tubercle e. in healthy person – initial lesions may heal and become latent before signs and symptoms occur 1. tubercles eventually calcify 2. bacillus can remain viable/dormant inside the tubercle for many years f. in unhealthy person – bacillus spreads to other parts of the lung and to other organs 3. Signs and Symptoms a. onset is gradual, can have active lesions before symptoms appear b. cough, low-grade fever in afternoon, anorexia, weight loss, fatigue, night sweats, hemoptysis (coughing up blood) c. chest pain, mucopurulent sputum (has a lot of mucus and pus) 4. Diagnosis a. early detection is very important because anti-tb meds are more effective in the early stages, fewer complications, helps prevent spread to others b. TB skin testing – food handlers, those working with children and health care workers, symptomatic or exposed to someone with TB 1. Mantoux skin test a. 1 mL of purified protein derivative (PPD) intradermally b. tuberculin skin test (TST) – formerly PPD test c. read 48 to 72 hours after injection d. positive if swelling 5 mm in diameter – if exposed or if immunocompromised e. induration more than 10 mm – immigrants where TB is prevalent, medical underserved persons, homeless f. induration of more than 15 mm if low risk g. contraindicated with hx of severe reaction h. indicates exposure, but does not indicate if active or inactive i. positive reaction indicates need for further evaluation j. once positive, always positive k. BCG vaccine is not contraindication, but must be considered when reading results c. Blood Testing 1. 2 tests approved by FDA 1. QuantiFERON-TB Gold (QFT-GIT) and TSpot -measures body reaction to TB; does not specify if active or latent MS-RESP #2 OUTLINE-2022 3 OF 13  d. Radiographic Exams and Sputum Cultures 1. CXR – will show calcified and healed lesions in the lungs 2. CT scan - more sensitive but usually not necessary 3. Acid-Fast Bacillus (AFB) sputum test is diagnostic- takes 1-3 weeks to get results back and 3 negative sputum test are required; may have to suction to obtain sputum or gastric washing (for pts that swallow sputum) 5. Treatment a. uncomplicated TB - tx outpatient b. extremely debilitated or have another chronic illness - hospitalized c. at least 4 drugs for extended period of time (6-9 months) - combination therapy is more effective d. Rifamate (rifampin (RIF) and isoniazid (INH) e. Rifater (rifampin (RIF), isoniazid (INH) and pyrazinamide (PZA) f. ethambul (EMB), rifapentine (RPT), Streptomycin (SM), others g. negative pressure isolation room h. N95 mask, HEPA mask - must be worn while in pt room; other precautions: and cover mouth when sneeze, properly dispose tissues, wear a mask when in crowds and do sputum test monthly to see how pt is reacting to treatment i. close contacts monitored with skin blood testing and treated with medication j. HIV positive, pregnant or breastfeeding, infant and children have specific protocols for meds that they follow k. promote immunity by good health practices (rest, adequate diet, etc) F. Extrapulmonary (Miliary) Tuberculosis 1. when tubercle bacillus attacks and damages other parts of the body than the lungs 2. most common is that is can affect the lymph nodes, bones, GI system, Urinary system, meninges (membrane that covers the spinal cord), reproductive system 3. s/s depend upon body part that is affected; potts disease (hunchback) G. Occupational Lung Disorders 1. causes – coal dust; dust from hemp, flax, and cotton processing; exposure to silica in air, asbestos (mesothelioma) II. Restrictive Pulmonary Disorders - Caused by decreased elasticity or decreased ability of chest wall to expand - Caused by disorders of CNS or neuromuscular system – myasthenia gravis, kyphosis, obesity A. Interstitial Pulmonary Disease 1. Sarcoidosis a. multisystem inflammatory disease that causes fibrous changes and lung tissue overtime b. cause is unknown but theory that it could be autoimmune c. African Americans are 10x more likely than caucasians to develop this (affects people 20-40 years in age) d. results in decreased functional lung tissue (not good gas exchange) e. most recover with tx of symptoms MS-RESP #2 OUTLINE-2022 4 OF 13  f. hx of persistent pulmonary disease - will tx with corticosteroids (will help suppress immune system which makes them more susceptible to infection )(end in ‘sone’) 2. Pulmonary Fibrosis a. causes include environmental pollution, some meds, occupational inhalation of lung irritants, smoking and radiation to chest b. occupational inhalation of lung irritants c. s/s dyspnea on excretion (shorter breath with activity), non-production cough, rales/crackles, clubbed fingers d. dx- ct scan of chest, pulmonary function test e. 20 – 25% survival rate at 10 years after diagnosis f. tx – pirfenidone or nintedanib (antifibrotic meds); sildenafil for advanced cases, lung transplant is option for some B. Pleuritis 1. aka pleurisy – inflammation of the pleura 2. most common cause is infection. can also be caused by meds, lupus and rheumatoid arthritis 3. pain is sharp, abrupt onset, pain felt more on inspiration which causes breathing to be more shallow (increases risk of hypostatic pneumonia 4. pleural friction rub - if pt holds breath and still have pain it is cardiac; if pt holds breath and it stops, it's the lungs 5. treat underlying cause, give angelisa for pain (respiratory depression- so no morphine) 6. intercostal nerve block for severe pleuritic pain- numbs some nerves to ribs C. Pleural Effusion 1. collection of fluid in pleural space 2. fluid can be transudative (thin, without protein) or exudative (thicker with cells, proteins, and other substances) 3. usually caused by pleural and lung inflammation; can be caused by any organ system 4. when pleuritis is combined with effusion can do thoracentesis to relieve symptoms and send to lab for diagnosis - can remove up to 500 mls D. Empyema 1. when pleural fluid is infected and becomes thick and pleurant 2. most are secondary to pneumonia; about 20% are secondary to thoracic surgery (open heart), chest tube insertion, thoracentesis 3. tx with chest tube to remove pus and antibiotics (need C&S of sputum, start on board spectrum then switch) III. Obstructive Pulmonary Disorders - Characterized problems moving air in and out of lungs - Caused by cigarette smoking, inhalation of irritants, chemicals, air pollution, agricultural chemicals, volcanic eruptions, fumes and dust - Can be genetic – Alpha-1 antitrypsin (AAT) –inhibits action of elastase – lack of results in destruction of lung tissue by elastase (enzyme); cystic fibrosis MS-RESP #2 OUTLINE-2022 5 OF 13  A. Bronchiectasis 1. chronic, results in walls of bronchi becoming thickened 2. result of frequent respiratory infections and frequent aspiration of food 3. in US 1 in 3 cases are d/t cystic fibrosis B. Cystic Fibrosis 1. genetic disease, that is more common in caucasians 2. excessive mucus production which is thick and tenacious(hard to expectorate it) 3. affects lungs, intestines sinuses, reproductive tract, sweat glands and pancreas 4. dx based on history, physical exam, genetic testing and sweat test (measure amount of chloride in sweat and with cystic fibrosis, level will be elevated) 5. lung damage due to excessive secretion of abnormally thick mucus, impaired action of cilia, airway obstruction, scarring d/t repeated infections 6. once pediatric disease because most pts that had CF died before adulthood, now pts can live 40 years and longer with aggressive respiratory treatment and antibiotics 7. now live to 8. ivacaftor – new treatment (approved in 2017) for people 2 years and older- treats the problem vs the symptoms 9. symptomatic treatment - bronchodilators (relaxes smooth muscles in airways), expectorants (help thin mucus), oral pancreatic enzymes (so pt does not suffer from malnutrition to decrease infection), double doses of fat soluble vitamins, mucolytics (helps decrease thickness of mucus), high protein, high calorie diet 10. dornase alfa (Pulmozyme) decreases the frequency of respiratory infections and improves lung function 11. breathing exercises and chest physiotherapy daily (percussion, postural drainage, vibrating vest) 12. lung transplant C. Chronic Obstructive Pulmonary Disease (COPD) - emphysema, chronic bronchitis, asthma 1. Etiology and Diagnosis a. smoking and AAT deficiency causes emphysema and chronic bronchitis b. risk factors – tobacco smoke exposure (90%), passive smoke, biomass fuel use (wood, crops, manure, some garbage used to produce heat), occupational exposure c. high risk groups firefighters, welders, farmers d. dx - based on history, physical exam, pulmonary function test, chest x-ray (more to help rule out other causes) 2. Treatment- bronchodilators, corticosteroid, decreasing exposure to lung irritants if possible, stopping smoking, influenza and pneumonia immunizations, pulmonary rehab, oxygen (want pulse ox between 88-92 because body is use to higher co2 level in body), high protein, high calorie diet; with exacerbation- IV corticosteroids and bronchodilators -lung volume reduction surgery (severe emphysema)- remove some of the damaged lung tissue; if severe, lung transplant D. Emphysema 1. Pathophysiology – destruction of alveoli and capillary walls results in blebs (small collection of air between lung and visceral pleura, if bursts MS-RESP #2 OUTLINE-2022 6 OF 13  leads to pneumothorax) leading to large, permanently dilated alveoli – traps inhaled air and makes exhalation difficult (decreases exchange of gasses and result in decreased lung elasticity) 2. Signs and Symptoms a. dyspnea- early symptom that gets worse as disease progresses (interferes with ADLs) b. coughing with small amount of mucoid sputum (more common in AM) c. diaphragm flattens due to over-inflation of the lungs, intercostals become rigid and ribs flare outward resulting in barrel chest d. start to muscles of neck and shoulders when breathing e. pink skin becomes pink 3. Treatment a. inhaled bronchodilators, steroids and oxygen E. Chronic Bronchitis 1. Pathophysiology a. excess secretion of thick, tenacious mucus which interferes with the flow of air and decreases the action of the cilia and see inflammatory damage of mucosa b. airways narrow d/t edema and air is trapped c. bronchi inflammation chronic when a cough is present for at least 3 months of the year for at least 2 years d. frequent will have frequent respiratory infections 2. Signs and Symptoms a. ranges from mildly irritating morning cough with small amounts of sputum to a severe disabling condition b. PFT will show increased residual volume (air left in lung after exhale) c. increased PaCO2 and decreased PaO2- ABG d. reddish blue skin d/t polycythemia (too many RBC in the blood) happens because body is compensating for chronic hypoxia so it starts overproducing RBC F. Asthma 1. Etiology a. factors: allergens, virus, toxins in environment or workplace, exercise, perfumes, genetics, obesity, emotional stress 2. Pathophysiology a. reversible airway obstruction, airway edema or swelling, and increased airway hypersensitivity b. inflammation in the airway result sin bronchospasm and edema c. cough, dyspnea, excessive mucus plugs smaller airways d. results in bronchoconstriction 3. Signs and Symptoms a. intermittent or constant, wheezy cough that is worse at night, SOB, chest tightness b. unrelieved attack results in status asthmaticus (asthma attacks bac to back with no relief) – very serious 1. respiratory without wheeze is a significant finding because it indicates that there is constriction of airway with very little air movement 2. can result in death d/t hypoxia 4. Treatment a. based on degree and frequency of symptoms MS-RESP #2 OUTLINE-2022 7 OF 13  b. treated by step system Table 14-3 pg 312 c. inhaled bronchodilators, glucocorticoids - inhibit inflammation d. theophylline- relaxes smooth muscle of airway e. anticholinergics-atropine- bronchodilation and decreases secretions f. mucolytics- thin mucus g. antibiotics h. O2 i. peak flow meter Fig 12-5 pg 270 -used to monitor effectiveness of therapy and ability to move air G. Complications of Chronic Obstructive Pulmonary Disease 1. Pulmonary Hypertension (PH) a. high blood pressure in blood vessels of the lungs; measured during catheterization of the right side of the heart with a pulmonary heart catheter (assess via femoral artery and feed catheter up to right side of heart) b. 5 classes based on cause 1. Type 1 - d/t drugs, toxins, heredity, HIV 2. Type 2 - d/t left side heart disease (left side CHF) 3. Type 3 - d/t COPD, hypoxemia 4. Type 4 - d/t chronic pulmonary blood clots 5. Type 5 - d/t all other causes c. medications to reduce pressure in the pulmonary vessels and to tx underlying cause (diuretics, digoxin, beta blockers) d. Type 1 has poorest prognosis; survival rate 5 years after diagnosis -57% e. Cor Pulmonale 1. enlargement of right side of heart due to PH 2. right side of heart has to pump harder and becomes enlarged 3. hypoxia leads to polycythemia (will make blood thicker, will increase hematocrit) 4. leads to venous congestion which can be seen as distended neck veins, RUQ tenderness because of liver congestion (blood gets backed up), peripheral edema, weight gain, ascites 5. tx - low flow oxygen, meds for HF, decrease fluid volume (lasix) f. Gastroesophageal Reflux Disease (GERD) 1. 2 x more likely in COPD 2. acid in esophagus stimulates bronchoconstriction and microaspiration 2. Nursing Management a. educate patient and family 1. identify problem areas, in terms of treatment, methods to cope and plans to accomplish goals 2. prevent exacerbations- avoiding irritation (inhaling) and infection 3. identify complications 4. need for exercise and activity 5. smoking cessation – critical a. pulmonary function gradually improves b. info must be offered to all patients c. support groups; nicotine patches, gum, nasal spray and inhalers; stress reduction and exercise MS-RESP #2 OUTLINE-2022 8 OF 13  d. decreases risk of lung cancer-10-20 years after stopped smoking, chances of lung cancer is equal to someone who has never smoked H. Lung Cancer 1. Etiology a. leading cause of cancer death worldwide b. typically 40 years and older c. cigarette smoking is the primary cause d. person that lives with a smoker has a 2x higher risk (2nd hand smoke) e. other risk factors: air pollution, asbestos, TB, COPD f. 15% men and 22% women survive more than 5 years because it’s not diagnosed until well advanced 2. Pathophysiology a. non-small cell lung cancer – 85% of lung cancer 1. adenocarcinoma, squamous cell carcinoma, large cell carcinoma - different types; usually in peripheral lung tissue, grows slowly, tends to metastasize to brain, bone, liver b. small cell lung cancer – 15% cases; tumor cell grows rapidly and often located near a major bronchis (center of lung, more localized) c. chronic irritation causes the structure of the cells to change, leading to dysplasia and tumor growth 3. Signs and Symptoms a. initially will have few s/s (cough, wheezing) b. as tumor grows, start to see symptoms like pain, dyspnea on excretion and blood-tinged sputum c. site of tumor can produce specific symptoms (tumor near trachea- horasiness, difficulty speaking) d. fatigue, anorexia, weight loss are less common because they are usually well advanced when diagnosis 4. Diagnosis- chest x-ray, sputum cytology, pet scan, biopsy, bronch 5. Treatment a. based on type of cancer and stage b. if early and localized- surgery to remove cancer 1. wedge resection- remove small area of lung (slice of pie) 2. segmental resection- the lung tissues that is affected along with blood vessels and bronchioles 3. lobectomy- remove affected lobe 4. pneumonectomy- remove entire lung - most common with small cell lung cancer; post op do not want to place on surgical side because structures of lung can shift and cause mediastinal shift c. may have radiation before and after d. some of these lung cancers are radiation resistant e. small cell lung cancer responds very well to chemo and radiation f. non-small cell lung cancer is very aggressive and difficult to treat unless caught early 1. surgery - if caught early 2. later stages - may do radiation/chemo to shrink cancer to give pt more time (not to cure) MS-RESP #2 OUTLINE-2022 9 OF 13 IV. Pulmonary Vascular Disorders A. Pulmonary Embolism (PE) 1. Etiology and Pathophysiology a. pulmonary blood vessel is blocked by a mass or a clot b. can be solid, liquid or gas (fat, air embolism)(DTV, ameoci fluid) c. interferes with gas exchange d. can be minor or life threatening 2. Signs and Symptoms a. depends on size and location; also if it was 1 clot or multiple b. respiratory distress, dyspnea, chest pain, cough, hemoptysis, anxiety c. maybe hypotension, tachycardia, confusion d. sudden onset of dyspnea with a drop in pulse ox, very suggestive of PE 3. Diagnosis a. rule out other causes b. D-Dimer (protein fragment mad when body dissolves a blood clot), not definitive because can have elevation of D-Dimer for other reasons c. Computed tomographic pulmonary angiography (CTPA) - looks at blood flow of lungs; definitive d. other tests: chest x-ray, echocardiogram, ecg, abg’s→ rule out cardiac 4. Treatment a. O2 b. depends on size and location and stability of pt c. IV Heparin d. stable patient - injectable heparin then switch to oral anticoagulant for 3 months (coumadin) e. thrombolytics - if large embolism and pt is not stable; clot buster f. pulmonary embolectomy- remove clot surgically g. IVC (inferior vena cava ) filter- insert catheter through groin and go into inferior vena cava and prevent further clots from getting into lung - allows blood cells to get through and not clots) h. nursing care- stay calm, elevate HOB, monitor vitals, notify dr, bedrest B. Pulmonary Hypertension 1. s/s: dyspnea; others: chest pain with activity, dizziness and 2. no cure 3. tx underlying cause 4. meds to dilate blood vessels – calcium channel blockers; anticoagulants; diuretics; digoxin; O2 C. Lung Transplantation 1. option for various end stage lung diseases 2. one lung, both lungs, heart/lung 3. no hx of malignancy within 2 years, no active tb, no substance addition for 6 months (drugs, alcohol), no renal or liver impairment 4. average wait: 6-7 months 5. most common cause of death after transplant is infection (within 4-6 weeks within surgery) 6. life long immunosuppressive therapy MS-RESP #2 OUTLINE-2022 10 OF 13 V. Chest Injuries A. Pneumothorax and Hemothorax 1. often result of a blunt or penetrating injury to a chest wall 2. causes: a partial or total collapse of 1 lung or both 3. due to a loss of negative pressure in the pleural space 4. can be spontaneous; things that can increase: tall, thin people, especially if they smoke; scuba dive; flying; mountain climbing 5. pneumothorax - may only need rest and O2 a. if amount of air minimal, dr can do needle aspiration or can use chest valve device b. greater amounts of air/fluid, will have a chest tube to water seal drainage 6. hemothorax- blood in space a. causes include laceration of the lung, heart, blood vessels or chest b. risk of mediastinal shift (everything shifts to one side (not were supposed to be)) c. thoracostomy tube and water seal drainage 7. s/s: sudden chest pain and tightness, increase pulse/respirations, decrease in BP, abnormal chest movement, absentee diminished lung sounds VI. Lung Disorders A. Pulmonary Edema 1. abnormal collection of fluid in the interstitial spaces of the lung and the alveoli 2. acute pulmonary edema is a medical emergency 3. classified as cardiogenic or noncardiogenic (meaning its r/t the heart or not) 4. left ventricular heart failure is the most common cause 5. non-cardiogenic causes – neurogenic pulmonary edema drowning, acute glomerulonephritis, inhalation injury, allergic reaction, and acute respiratory distress syndrome →crackles/rales, pink, frothy sputum 6. tx: high fowler's, oxygen, CPAP or intubation, lasix (diuretics), morphine, tx underlying heart disorder is cardiac related, monitor I&O, monitor respiratory/cardiac function B. Acute Respiratory Distress Syndrome 1. Etiology and Pathophysiology a. form of acute lung injury result of pulmonary changes associated with sepsis, major trauma, major injury, any critical illness b. alveoli capillary membrane is injured and becomes permeable to intravascular fluid causing the alveoli to fill with fluid and interferes with gas exchange c. leads to pulmonary edema and causes lung tissue to become more stiff resulting in severe hypoxemia e. more dangerous if patient has multisystem disorders (25-40% mortality rate) 2. Signs and Symptoms a. dyspnea, tachycardia, fine crackles b. tachypnea leads to hypoxemia and alkalosis c. symptoms worsen as condition progresses due to increased fluid accumulation and decreased lung compliance (can be within 12 to 48 hours of onset) 3. Diagnosis a. physical exam, history, ABGs, chest x ray MS-RESP #2 OUTLINE-2022 11 OF 13  b. sudden onset; hypoxemia despite supplemental O2 4. Treatment: intubation and ventilator, CPAP, antibiotics, nutritional support, fluid and electrolytes, prone position to decrease respiratory effort C. Respiratory Failure 1. result of not enough O2 or excessive CO2, acute or chronic 2. PaO2 less than 60 (normal: 80 to 100); result of not enough oxygen diffusing from the alveoli to the pulmonary capillaries 3. hypercapnia is a result of hypoventilation 4. PaCO2 greater than 50 (normal: 35 to 45) 5. chronic lung disease may result in chronic state of respiratory failure 6. constant hypoxia leads to constant SOB 7. abrupt onset and severity of symptoms determines the acuteness of the condition 8. s/s – restless, agitation, confusion, increased respiratory and pulse rates, increased blood pressure, orthopneic position, difficulty speaking without pausing for breath, diaphoresis (sweating), retractions, use of accessory muscles, cyanosis (late sign) can lead to cardiac arrest 9. tx – O2, ventilator, reduce and remove secretions, bronchodilators, correct acidosis, tx underlying cause, ICU, extracorporeal membrane oxygenation (ECMO) in some patients (similar to heart lung bypass machine) VII. Common Therapeutic Measures A. Intrathoracic Surgery 1. open chest wall and enter pleural cavity – needed to resect lungs; repair heart, great vessels or defects of the esophagus 2. Video-assisted thoracic surgery (VATS) is a type of minimally invasive thoracic surgery that can remove parts of the diseased lung and lymph nodes. In video-assisted thoracoscopic surgery (VATS), a small tube called a thoracoscope is inserted through a small cut (incision) between the ribs - minimally invasive 3. Pre-op care a. assess respiratory status, improve respiratory status as much as possible (exercises to improve strength of chest, shoulder, and accessory muscles of respiration), arm and leg exercises to prevent thrombophlebitis post op – more likely with standard thoracotomy than VATS b. incentive spirometer, chest tubes, suctioning, mechanical ventilation 4. Post-op care a. turn and reposition, cough and deep breathe, monitor respiratory status, vital signs, monitor chest tubes b. if VATS – OOB in chair within 4 to 6 hours of OR, resume ADLs 3 to 4 days, return to work within 1 week c. if standard thoracotomy – 4 to 6 week recovery d. pain management is critical to promote early ambulation and help with deep breathing which helps prevent atelectasis and pneumonia -have to monitor for pneumothorax (lung sounds, chest movement, pulse ox);subcutaneous emphysema(cripadis-air leaks out from somewhere else MS-RESP #2 OUTLINE-2022 12 OF 13  and got to another place), gastric distention, paralytic ileus, paralysis lie on back or operative side 4. Closed Chest Drainage/Suction Fig 14-4 pg 310, 14-6 pg 313, 14-7 pg 313 a. Purpose 1. promotes air / secretions to drain from pleural space / cavity 2. promotes re-expansion of lung 3. closed to prevent air from entering into chest – if opened or disconnected will allow air to rush in and collapse lung 4. pleural space is negative pressure to pull air into lungs with inspiration 5. if pleura is cut = increases pressure into space and collapses lung b. Maintenance- collection device has to be upright and below level of chest; note characteristics and amount of drainage; do not empty, once full, change and attach new one; include in I&O; check for water fluctuations (want to see, if do not see, chest tube may be clogged or lung has re expanded); if not draining, can milk tubing, ensure tubing is not kinked; gravity or suction; continuous bubbling can indicate air leak; monitor pt’s for respiratory distress, lung sounds, symmetry of chest movement and subcutaneous emphysema; Always have clamps at bedside to double clamp as close to the chest wall to prevent air from leaking out. keep sterile saline near bed side incase of disconnection; nurse is responsible for making sure tubing stays connected they are secure c. Names of Products 1. Pleur-evac 2. Emerson Pump 3. Thoraclex 4. Bently Bottle 5. Heimlich chest drainage tube d. Activity – as much as tubing allows can walk with iy J. Miscellaneous 1. Guillain Barre Syndrome- neuromuscular disease, progressive ascending neuromuscular or paralysis, start from feet to up and can para;yxed diaphragm which can lead to pneumonia, respiratory failure 2. Strep Throat- may be followed by glomerulonephritis or rheumatic fever 3. Pulmonary Edema- medical emergency due to left sided hf or fluid overload, s/s have pink bubbly(frothy) sputum, drowning, rales, hypoxic used diuretic, digoxin 4. Tracheobronchitis- known as ‘croup’ 5. Carbon Monoxide (CO) Poisoning a. accidental d/t faulty furnace or car/engine running without adequate ventilation b. s/s: cherry red skin, headache, N, V, unconscious, c. treat = high O2 concentrations to force CO off Hgb and b/c the co binded to the hgb which takes it everywhere, so must take them into a hyperbaric chamber. MS-RESP #2 OUTLINE-2022 13 OF 13