Management of Patients with Chest and Lower Respiratory Tract Disorders PDF

MANAGEMENT OF PATIENTS WITH CHEST AND LOWER RESPIRATORY TRACT DISORDER  GLOSSARY Acute Lung Injury: A broad term for a condition where the lungs cannot provide enough oxygen to the blood. Acute Respiratory Distress Syndrome (ARDS) is a severe form of this i...

MANAGEMENT OF PATIENTS WITH CHEST AND LOWER RESPIRATORY TRACT DISORDER  GLOSSARY Acute Lung Injury: A broad term for a condition where the lungs cannot provide enough oxygen to the blood. Acute Respiratory Distress Syndrome (ARDS) is a severe form of this injury. Acute Respiratory Distress Syndrome (ARDS): A severe reaction of the lungs to various injuries, both from the lungs and other parts of the body. It includes fluid in the lungs, bleeding into the air sacs, lung collapse, stiffness of the lungs, and severe low blood oxygen levels. Asbestosis: Lung disease caused by inhaling asbestos fibers, leading to widespread scarring of the lung tissue. Aspiration: Breathing in substances such as food, stomach acid, or saliva into the lungs. Atelectasis: Collapse or lack of air in the lung air sacs (alveoli), often due to low air intake, blockage, or pressure on the lung. Central Cyanosis: A bluish tint to the skin or mucous membranes because the blood doesn't carry enough oxygen. Consolidation: When lung tissue becomes solid instead of spongy due to collapse of air sacs or infection like pneumonia. Cor Pulmonale: Enlargement of the right side of the heart caused by lung disease or other lung problems.  GLOSSARY Empyema: Collection of pus in the space between the lungs and the chest wall. Fine-Needle Aspiration: A procedure using a thin needle inserted into the chest to collect cells from a mass or tumor, often guided by imaging techniques. Hemoptysis: Coughing up blood from the lungs or lower airways. Hemothorax: Blood accumulating in the chest cavity, causing partial or complete lung collapse, often due to injury or surgery. Induration: Hardening of an area of the body, often used to describe a firm spot on the skin that appears in a positive tuberculosis test. Open Lung Biopsy: A surgical procedure to take a sample of lung tissue through a small chest incision. Orthopnea: Difficulty breathing when lying down.  GLOSSARY Pleural Effusion: Buildup of excess fluid in the space between the layers of the pleura outside the lungs. Pleural Friction Rub: A grating sound made when inflamed layers of the pleura rub together. Pleural Space: The gap between the two layers of the pleura (lining of the lung). Pneumothorax: Air in the pleural space causing part or all of a lung to collapse. Pulmonary Edema: Fluid buildup in the lungs' air sacs. Pulmonary Embolism: Blockage in one of the pulmonary arteries in the lungs, typically due to blood clots, air bubbles, or fat droplets. Purulent: Containing or producing pus.  GLOSSARY Restrictive Lung Disease: Condition where the lung's ability to expand is reduced, decreasing lung volume. Tension Pneumothorax: A severe type of pneumothorax where the pressure in the chest increases with each breath, requiring emergency treatment. Thoracentesis: A procedure where a needle is inserted into the pleural space to remove excess fluid, reducing pressure on the lungs and helping to diagnose the cause. Transbronchial: Pertaining to or performed through the bronchial wall, like in a lung biopsy. Ventilation–Perfusion Ratio (V/Q Ratio): The balance between the air reaching the lungs and the blood flow in the lungs, crucial for effective gas exchange.  ATELECTASIS Atelectasis is the closure or collapse of the lung's air sacs (alveoli) and can be identified by x-ray or clinical symptoms. It is a common chest x-ray finding. Atelectasis can be acute or chronic, ranging from small, undetectable areas to large areas with significant lung volume loss. Acute atelectasis often occurs after surgery or in individuals with shallow breathing patterns due to immobility. It can also be caused by excess secretions or mucus blocking airflow. Chronic atelectasis occurs more gradually and is often due to long-term airway obstructions, such as those caused by lung cancer.  PATHOPHYSIOLOGY Atelectasis happens when the alveoli (tiny air sacs in the lungs) collapse. This can be due to either reduced airflow (nonobstructive) or a blockage in the airways (obstructive). Obstructive atelectasis is more common and occurs when trapped air is absorbed into the bloodstream, causing the alveoli to collapse. Causes include foreign objects, tumors, mucus buildup, pain, prolonged lying down, and certain surgeries. Postoperative patients are at high risk due to shallow breathing from anesthesia, pain, and lying flat. This can lead to mucus buildup and airway obstruction, making it hard to cough effectively and causing the alveoli to collapse.  CLINICAL MANIFESTATIONS General Symptoms Chronic Atelectasis: Increasing shortness of breath (dyspnea) Similar symptoms to acute atelectasis Coughing Increased risk of lung infections due to prolonged Sputum production collapse Acute Atelectasis: Severe breathing difficulty Rapid heartbeat (tachycardia) Fast breathing (tachypnea) Chest pain Bluish skin (cyanosis) – late sign of low oxygen Trouble breathing while lying down Anxiety  ASSESSMENT AND DIAGNOSTIC Clinical Signs: Increased effort to breathe FINDINGS Low oxygen levels (hypoxemia) Crackling sounds in the affected area Diagnostic Tools: Chest X-ray: Can show patchy areas or consolidated lung tissue before symptoms appear. Pulse Oximetry (SpO2):Measures oxygen saturation; levels below 90% indicate low oxygen. Partial Pressure of Arterial Oxygen (PaO2): May show lower-than-normal oxygen levels. Quality and Safety Alert: Tachypnea (rapid breathing), dyspnea (shortness of breath), and mild to moderate hypoxemia are key indicators of the severity of atelectasis. Nursing Measures: PREVENTION Frequent Position Changes: Shift the patient’s position regularly, especially from lying down to sitting up. Early Mobilization: Encourage moving from bed to chair and walking as soon as possible. Deep Breathing Exercises: Teach and reinforce deep breathing techniques (every 2 hours) to expand the lungs and clear secretions. Incentive Spirometry: Use devices to encourage deep breathing and prevent airway closure. Secretion Management: Directed coughing, SuctioningAerosol nebulizer treatments, Chest physiotherapy (postural drainage and percussion), Preventing Atelectasis Change the patient's position often. Promote early movement and ambulation. Encourage deep breathing and coughing. Educate on proper use of incentive spirometry. Administer opioids and sedatives carefully to avoid respiratory depression. Perform postural drainage and chest percussion if needed. Use suctioning to clear secretions if necessary. Goals: MANAGEMENT Improve ventilation and Remove secretions First-Line Measures: Frequent Position Changes: Turn the patient regularly. Early Ambulation: Encourage movement and walking. Lung Volume Expansion: Deep-breathing exercises and Incentive spirometry Coughing: To clear secretions For Unresponsive Cases or Inability to Perform Exercises: Positive End-Expiratory Pressure (PEEP): Mask system providing expiratory resistance (10-15 cm H2O). Continuous Positive Pressure Breathing (CPPB) or Bronchoscopy Questions to Consider Before Advanced Therapy: Has the patient had enough time to try deep-breathing exercises? Has the patient been properly educated and coached on these exercises? Have factors affecting ventilation or patient effort been addressed (ex: lack of movement, excessive pain, or sedation)?  RESPIRATORY INFECTIONS Acute Tracheobronchitis Acute inflammation of the mucous membranes in the trachea and bronchial tree. Cause: Often follows an upper respiratory tract infection. Risk Factors: Patients with viral infections have decreased resistance, increasing the risk of secondary bacterial infections. Prevention: Proper treatment of upper respiratory infections helps prevent acute bronchitis.  PATHOPHYSIOLOGY Acute tracheobronchitis is when the lining of the trachea and bronchial tubes becomes inflamed. This inflammation causes the production of thick, pus-filled mucus. It often follows an upper respiratory infection and can be caused by bacteria like “Streptococcus pneumoniae” or “Haemophilus influenzae”, or by fungi such as “Aspergillus”. Irritants like smoke or pollutants can also lead to this condition. To find out what’s causing the infection, doctors use a sputum culture to test the mucus. A special type called ventilator-associated tracheobronchitis can occur in people on long-term mechanical ventilation and needs careful management to prevent more serious lung infections.  CLINICAL MANIFESTATIONS Early Symptoms: Dry, irritating cough Small amount of mucoid (mucus) sputum Sternal soreness from coughing Fever or chills Night sweats Headache General feeling of illness (malaise) Progressing Symptoms: Shortness of breath Noisy breathing (stridor and wheezing) Production of purulent (pus-filled) sputum Severe Symptoms: Blood-streaked sputum due to irritation of the airway lining  MEDICAL MANAGEMENT Antibiotics: Prescribed based on symptoms, sputum quality, and culture results. Avoid Antihistamines:They can dry out secretions, making them harder to cough up. Increased Fluid Intake:Helps thin mucus, making it easier to clear. Managing Severe Cases: Suctioning and Bronchoscopy: May be needed to remove thick, purulent secretions. Endotracheal Intubation: Rarely needed for severe cases leading to respiratory failure. Symptomatic Treatment: Increase Moisture: Use cool vapor or steam inhalations to soothe the airways. Moist Heat: Apply to the chest to relieve pain. Mild Analgesics: For pain relief.  NURSING MANAGEMENT(HOME SETTINGS) Bronchial Hygiene: Increase Fluid Intake: Helps thin and clear mucus. Directed Coughing: Encouraged to remove secretions. Patient Positioning: Sit Up Frequently: Helps with effective coughing and prevents mucus buildup. Antibiotic Use: Complete the Full Course: Important if antibiotics are prescribed for an infection. Manage Fatigue: Avoid Overexertion: Rest to prevent relapse or worsening of the infection.  PNEUMONIA Inflammation of the lung tissue caused by bacteria, mycobacteria, fungi, or viruses. Pneumonia and influenza are major causes of death in the U.S. In 2009, pneumonia caused about 51,000 deaths and 1.1 million hospital discharges.  CLASSIFICATION Community-Acquired Pneumonia (CAP): Occurs outside of a healthcare setting or within the first 48 hours of hospital admission. Not associated with healthcare contact. Health Care–Associated Pneumonia (HCAP): Occurs in nonhospitalized patients with significant healthcare contact, including: Hospitalization for 2+ days in the past 90 days. Residence in a nursing home or long-term care facility. Recent antibiotic therapy, chemotherapy, or wound care. Hemodialysis. Home infusion or wound care. Contact with someone with multidrug-resistant bacteria.  CLASSIFICATION Hospital-Acquired Pneumonia (HAP): Occurs 48 hours or more after hospital admission. Not present at the time of admission. Ventilator-Associated Pneumonia (VAP): A type of HAP that develops 48 hours or more after endotracheal intubation.  RISK FACTORS FOR PNEUMONIA BASED ON PATHOGEN TYPE Penicillin-Resistant and Drug-Resistant Pneumococci: Pseudomonas aeruginosa: Age > 65 years Structural lung disease Alcoholism (e.g., bronchiectasis) Recent beta-lactam therapy (e.g., cephalosporins) in Corticosteroid therapy the past 3 months Recent broad-spectrum Immunosuppressive disorders antibiotic use (>7 days in Multiple medical conditions the past month) Exposure to children in daycare Enteric Gram-Negative Bacteria: Living in a long-term care facility Underlying heart or lung disease Multiple medical conditions Recent antibiotic therapy  COMMUNITY-ACQUIRED PNEUMONIA Occurs in the community or within the first 48 hours after hospitalization. Hospitalization: Depends on the severity of the pneumonia. Over 5 million cases annually in the U.S. More than 915,000 cases in adults 65 and older. Common Pathogens: Streptococcus pneumoniae (S. pneumoniae): Most common in people under 60 without comorbidities and in those over 60 with comorbidities. Can cause various infections like pneumonia, otitis media, and rhinosinusitis. Haemophilus influenzae (H. influenzae): Common in older adults and those with chronic illnesses (e.g., COPD, alcoholism, diabetes). Symptoms can be similar to other bacterial pneumonias. Mycoplasma pneumoniae: Spread by respiratory droplets.  Viruses: Common in infants and children but less so in adults. In immunocompromised adults, common viruses include cytomegalovirus, herpes simplex virus, adenovirus, and respiratory syncytial virus. Symptoms are often similar to bacterial pneumonia. HEALTH CARE–ASSOCIATED PNEUMONIA Often caused by multidrug-resistant (MDR) pathogens. Importance: Early identification in settings like emergency departments is crucial. Treatment: Initial antibiotic treatment must be prompt and may differ from community-acquired pneumonia (CAP) due to MDR bacteria.  HOSPITAL-ACQUIRED PNEUMONIA Develops 48 hours or more after hospital admission. Does not appear to be present at admission. Risk Factors: Impaired Host Defenses: Severe illness, comorbid conditions, malnutrition. Hospital Factors: Prolonged hospitalization, supine positioning, aspiration, use of respiratory devices. Intervention-Related Factors: Central nervous system depression, prolonged intubation, use of nasogastric tubes. Immunocompromised Patients: Higher risk for HAP. Common Organisms: Gram-Negative Bacteria: Enterobacter, E. coli, H. influenzae, Klebsiella, Proteus, Serratia, Pseudomonas aeruginosa. Gram-Positive Bacteria: Methicillin-sensitive or resistant Staphylococcus aureus (MRSA), S. pneumoniae. Symptoms: Common Signs: New pulmonary infiltrate on chest X-ray, fever, respiratory symptoms, purulent sputum, leukocytosis. Specific Symptoms: Cough, sputum production, low-grade fever, malaise. Severe cases may involve pleural effusion, high fever, and tachycardia. Treatment Considerations: Resistance: Overuse of antibiotics contributes to drug-resistant bacteria. Prevention: Isolation and contact precautions for MRSA, careful antibiotic use.  VENTILATOR-ASSOCIATED PNEUMONIA A subtype of hospital-acquired pneumonia (HAP) occurring in patients who have been intubated and on mechanical ventilation for at least 48 hours. Most common infection in intensive care units (ICUs). Accounts for 25% of infections in critically ill patients. Impact: Contributes significantly to ICU morbidity and mortality. Estimated mortality rate: 8% to 15%. High cost: ~$40,000 per patient; increases ICU length of stay. Timing and Bacteria: Within 96 hours of ventilation: Typically due to antibiotic-sensitive bacteria present before admission. After 96 hours of ventilation: More often associated with multidrug-resistant (MDR) bacteria. Prevention: Key to reducing the incidence and impact of VAP. Includes various bundled interventions  PNEUMONIA IN THE IMMUNOCOMPROMISED HOST Types of Pneumonia: Common Organisms: Pneumocystis Pneumonia (PCP): Caused by Pneumocystis PCP: Often seen in AIDS patients, rare in jiroveci. immunocompetent people. Fungal Pneumonias: Caused by various fungi. Other Pathogens: S. pneumoniae, S. Mycobacterium Tuberculosis: Tuberculosis pneumonia. aureus, H. influenzae, P. aeruginosa, M. Causes of Immunocompromised State: tuberculosis. Use of corticosteroids or immunosuppressive drugs. Gram-Negative Bacilli: Klebsiella, Chemotherapy. Pseudomonas, E. coli, Enterobacter, Nutritional depletion. Proteus, Serratia. Broad-spectrum antibiotics. Clinical Presentation: Acquired Immunodeficiency Syndrome (AIDS). Similar to other types of pneumonia. Genetic immune disorders. PCP: Subtle onset with progressive Long-term mechanical ventilation. shortness of breath, fever, and a dry Frequency: cough. Increasing in patients with compromised immune systems. Can also occur in immunocompetent individuals. ASPIRATION PNEUMONIA Pneumonia caused by substances entering the lower airway, including bacteria, gastric contents, or irritants. Causes: Bacterial Aspiration: Most common; bacteria from the upper airways enter the lungs. Non-Bacterial Aspiration: Includes gastric contents, chemicals, or irritating gases. Common Pathogens: Anaerobes, S. aureus, Streptococcus species, Gram-negative bacilli Impact: Impairs lung defenses. Causes inflammatory changes and bacterial growth leading to pneumonia. Settings: Can occur in both community and hospital settings.  PATHOPHYSIOLOGY Pneumonia occurs when the lung’s defense mechanisms fail to keep out infectious particles or harmful substances. Normally, the upper airway protects the lower lungs, but when this defense is compromised, bacteria from the mouth or throat can be inhaled into the lungs. This leads to an inflammatory response in the alveoli (air sacs), causing them to fill with fluid and white blood cells. This fluid interferes with the exchange of oxygen and carbon dioxide, making it hard for the body to get enough oxygen into the blood and remove carbon dioxide. The blocked and inflamed areas of the lungs also cause a mismatch in ventilation and blood flow, resulting in low oxygen levels in the blood. Pneumonia can affect large areas of the lung (lobar pneumonia) or be more scattered and patchy (bronchopneumonia), which is more common.  RISK FACTORS Cancer, COPD, smoking, and mucus production can obstruct normal lung function. Patients with weakened immune systems or low neutrophil counts are at higher risk. Smoking: Disrupts lung defense mechanisms. Prolonged inactivity and shallow breathing increase risk. Depressed Cough Reflex: Caused by medications, weakness, or unconsciousness. NPO Status and Tubes: Placement of feeding or breathing tubes can increase risk. Lying on the back without airway protection. Alcohol Intoxication: Impairs reflexes and immune response. General Anesthesia and Sedatives: Can reduce breathing effectiveness. Advanced Age: Associated with weakened reflexes and nutritional issues. Unclean Respiratory Equipment Transmission from Health Care Providers  PREVENTIVE MEASURES Promote coughing and expectoration to clear secretions. Encourage quitting smoking to reduce risk. Use special precautions to prevent infection. Frequently reposition patients and promote lung expansion exercises. Use suctioning and chest physical therapy as needed. Maintain good oral hygiene and check tube placement to minimize aspiration risk. Keep the head of the bed elevated at least 30 degrees. Monitor for signs of pneumonia in patients receiving antibiotics. Encourage moderate alcohol consumption and prevent aspiration in cases of intoxication. Observe breathing patterns post-anesthesia and adjust medications accordingly. Encourage turning, ambulation, breathing exercises, and a nutritious diet. Ensure respiratory equipment is properly cleaned and participate in quality improvement. Practice strict hand hygiene and educate health care providers.  CLINICAL MANIFESTATIONS Common Symptoms: Sputum Changes: Sudden chills and high fever Thick, yellow, or green sputum Sharp chest pain that worsens with deep Rusty or blood-streaked sputum in some breathing or coughing types of pneumonia Fast breathing and difficulty breathing In Immunocompromised Patients: Gradual Onset: Fever, crackling sounds in the lungs Nasal congestion, sore throat, headache Changes in lung sounds on examination Mild fever, chest pain, muscle aches, rash In COPD Patients: Cough with thick or yellow-green sputum Might only show increased sputum or slight Severe Cases: breathing changes Flushed cheeks, blue lips or nails (sign of low oxygen) Difficulty breathing when lying down; prefers to sit up ASSESSMENT AND DIAGNOSTIC FINDINGS Diagnosis: History: Recent respiratory infection Physical Examination Chest X-Ray: To check for lung abnormalities Blood Culture: To detect bacteria in the bloodstream Sputum Examination: To identify the causative organism Sputum Collection: Invasive Procedures: Procedure: Sputum Collection: a. Rinse mouth with water Nasotracheal or orotracheal suctioning b. Breathe deeply Fiberoptic bronchoscopy (used in severe, chronic, or c. Cough deeply hard-to-diagnose cases, or in patients on a d. Collect sputum in a sterile container ventilator)  PREVENTION Pneumococcal Vaccination: For Adults 65 and Older: One-time vaccination with pneumococcal polysaccharide vaccine (PPSV) is recommended. Revaccination: If 5 years or more have passed since the last dose, a second PPSV dose is recommended for those 65 and older. First Vaccination at 65 or Older: Only one dose is needed, regardless of medical conditions. MEDICAL MANAGEMENT -PHARMACOLOGIC THERAPY CAP 1. Streptococcal Pneumonia (Streptococcus pneumoniae) Treatment: PCN Sensitive: Penicillin, amoxicillin, ceftriaxone, cefotaxime, cefpodoxime, cefprozil, or a macrolide PCN Resistant: Levofloxacin, moxifloxacin, vancomycin, or linezolid Complications: Shock, pleural effusion, superinfections, pericarditis, and otitis media 2. Haemophilus Influenzae (Haemophilus influenzae) Treatment: Doxycycline, 2nd- or 3rd-generation cephalosporin, or a fluoroquinolone Complications: Lung abscess, pleural effusion, meningitis, arthritis, pericarditis, and epiglottitis 3. Legionnaires' Disease (Legionella pneumophila) Treatment: Azithromycin or a fluoroquinolone Complications: Hypotension, shock, and acute renal failure 4. Mycoplasma Pneumoniae (Mycoplasma pneumoniae) Treatment: Macrolide or doxycycline Complications: Aseptic meningitis, meningoencephalitis, transverse myelitis, cranial nerve palsies, pericarditis, myocarditis 5. Viral Pneumonia (Influenza, Adenovirus, Parainfluenza, CMV, Coronavirus, Varicella-Zoster) Treatment: Symptomatic treatment; for high-risk patients, oseltamivir (Tamiflu) or zanamivir (Relenza), plus other agents depending on the virus type Complications: Superimposed bacterial infection, bronchopneumonia, reinfection, and acute respiratory failure 6. Chlamydial Pneumonia (Chlamydophila pneumoniae) Treatment: Macrolide or doxycycline Complications: reinfection, and acute respiratory failure  HAP AND HCAP 1. Pseudomonas Pneumonia 2. Staphylococcal Pneumonia Treatment: Treatment: Oxacillin (Bactocill) or Nafcillin (Nalline) for MSSA Ceftazidime (Fortaz) Vancomycin (Vancocin) or Linezolid (Zyvox) for MRSA or PCN allergy Ciprofloxacin (Cipro) Complications: Cefepime (Maxipime) Pleural effusion, pneumothorax, lung abscess, empyema, Aztreonam (Azactam) meningitis, endocarditis Imipenem-cilastatin (Primaxin) Mortality rate: 25%-60% Meropenem (Merrem) 3. Klebsiella Pneumonia Piperacillin-tazobactam (Zosyn) Treatment: +/- Gentamicin (Garamycin) Ceftazidime (Fortaz) Imipenem (Primaxin) Complications: Meropenem (Merrem) Severe hypoxemia, cyanosis, Piperacillin-tazobactam (Zosyn) necrotizing infection, frequent +/- Gentamicin (Garamycin) or Ciprofloxacin (Cipro) bacteremia Complications: Mortality rate: 40%-60% Lung abscesses, pleural effusion, empyema, necrotizing infections Requires vigorous and prolonged treatment PNEUMONIA IN THE IMMUNOCOMPROMISED HOST 1. Pneumocystis Pneumonia (Pneumocystis jirovecii) Treatment: Trimethoprim/sulfamethoxazole (TMP-SMZ) Complications: Respiratory failure Mortality rate: 15%-20% if not treated 2. Fungal Pneumonia (Aspergillus fumigatus) Treatment: Voriconazole (Vfend) For invasive disease: Amphotericin B or Liposomal Amphotericin B (L-AMB), or Caspofungin (Cancidas) Lobectomy may be needed for fungus ball Complications: Dissemination to brain, myocardium, and thyroid gland  PNEUMONIA IN THE IMMUNOCOMPROMISED HOST 3. Tuberculosis Pneumonia (Mycobacterium tuberculosis) Treatment: Isoniazid (INH) Rifampin (Rifadin) Ethambutol (Myambutol) Pyrazinamide (PZA) Complications: Reinfection and acute respiratory infection Mortality rate: