Essentials of Human Diseases and Conditions - Respiratory System Diseases (2015) PDF

9 Diseases and Conditions of the Respiratory System CHAPTER OUTLINE Orderly Function of the Respiratory System, 443 Respiratory Syncytial Virus Pneumonia, 467 Common Cold/Upper Respiratory Tract Histoplasmosis, 468 Infection, 446...

9 Diseases and Conditions of the Respiratory System CHAPTER OUTLINE Orderly Function of the Respiratory System, 443 Respiratory Syncytial Virus Pneumonia, 467 Common Cold/Upper Respiratory Tract Histoplasmosis, 468 Infection, 446 Influenza, 469 Sinusitis, 447 Chronic Obstructive Pulmonary Disease, 472 Pharyngitis, 449 Acute and Chronic Bronchitis, 472 Bronchiectasis, 474 Nasopharyngeal Carcinoma, 450 Asthma, 475 Laryngitis, 451 Pulmonary Emphysema, 475 Deviated Septum, 452 Pneumoconiosis, 477 Nasal Polyps, 453 Pleuritis, 478 Anosmia, 454 Pneumothorax, 479 Epistaxis (Nosebleed), 455 Hemothorax, 481 Tumors of the Larynx, 455 Flail Chest, 481 Laryngeal Cancer, 457 Pulmonary Tuberculosis, 482 Hemoptysis, 458 Infectious Mononucleosis: Epstein-Barr Virus Atelectasis, 459 Infection, 484 Pulmonary Embolism, 460 Adult Respiratory Distress Syndrome, 485 Pneumonia, 463 Sarcoidosis, 486 Pulmonary Abscess, 465 Lung Cancer, 487 Legionellosis (Legionnaires Disease and Pontiac Fever), 466 LEARNING OBJECTIVES After studying Chapter 9, you should be able to: 4. Name some systemic disorders that might cause 1. Explain the process of respiration. epistaxis. 2. Discuss the causes and medical treatment for (a) 5. Discuss the prognosis of cancer of the larynx. the common cold, (b) sinusitis, and (c) pharyngitis. 6. Define atelectasis and discuss some possible 3. Name the treatment of choice for nasal polyps. causes. 442  CHAPTER 9 Diseases and Conditions of the Respiratory System 443 7. Compare the clinical pictures of (a) a patient with 17. Describe the presenting symptoms of pleurisy. pulmonary embolism and (b) one with 18. Explain the difference between pneumothorax pneumonia. and hemothorax. 8. List some health hazards of common molds. 19. Describe the cause of the instability of the chest 9. List some possible causes of pulmonary abscess. wall in a patient with flail chest. 10. Compare Legionnaires’ disease with Pontiac fever. 20. Discuss contributing factors to, and concern 11. Explain who is at greatest risk for (a) respiratory about, the rising prevalence of pulmonary syncytial virus (RSV) pneumonia and (b) tuberculosis (TB). histoplasmosis. 21. Describe the clinical course of infectious 12. List the groups recommended to receive mononucleosis. prophylactic use of influenza vaccines. 22. Explain the pathologic changes of the lungs in 13. Recall what the acronym COPD stands for. adult respiratory distress syndrome (ARDS). 14. Contrast the pathologic course of acute bronchitis 23. Explain what determines the prognosis of with that of chronic bronchitis. sarcoidosis. 15. Compare the pathology involved in bronchiectasis 24. Name the leading cause of cancer deaths with that of pulmonary emphysema. worldwide for both men and women. 16. Name and describe three causes of 25. Explain the possible health consequences of pneumoconiosis. smoking tobacco. KEY TERMS anosmia (an-OZ-me-ah) laryngectomy (lar-in-JECK-toh-me) anthracosis (an-thrah-KOE-sis) lymphadenitis (limf-ad-eh-NIGH-tis) aphonia (ah-FOE-nee-ah) lymphadenopathy (limf-ad-eh-NOP-ah-thee) asbestosis (as-beh-STOH-sis) pneumoconiosis (nu-moh-koh-nee-OH-sis) aspiration (as-pih-RAY-shun) rhonchi (RONG-ki) circumoral cyanosis (sir-kum-OH-ral sigh-an-OH-sis) silicosis (sill-ih-KO-sis) dysphonia (dis-FOE-nee-ah) sinusotomy (sigh-nus-OT-oh-me) epistaxis (ep-ih-STAK-sis) stridor (STRY-dor) exsanguination (eck-sang-win-AY-shun) syncytial virus (sin-SIGH-shal virus) hemoptysis (he-MOP-tih-sis) tachypnea (tach-ip-NEE-ah) deoxygenated venous blood from the heart to the ORDERLY FUNCTION OF lungs; pulmonary capillaries in which gas exchange THE RESPIRATORY SYSTEM occurs; and pulmonary veins, which return the freshly oxygenated blood to the heart for systemic circulation. The primary function of the pulmonary system is Lung tissue itself is supplied with oxygen and nutri- ventilation and respiration. Respiration maintains life ents by the blood supply that is carried to it by the by supplying oxygen to organs, tissues, and cells and bronchial arteries. allowing for the removal of carbon dioxide (a waste The lungs, along with the kidneys, have a major product of metabolism). This process is made possible metabolic function: the maintenance of acid-base by ventilation (the bellows-like action of the chest) (pH) balance of the blood. Lack of oxygen with hyper- and healthy lung tissue that is adequately perfused capnia (increased carbon dioxide in the blood) causes with blood. Breathing is controlled by the central respiratory acidosis; hyperventilation may produce nervous system; nerve stimulation of breathing begins hypocapnia (a decreased amount of carbon dioxide in in the medulla oblongata and pons. Pulmonary circu- the blood), causing respiratory alkalosis. In both con- lation is composed of pulmonary arteries that carry ditions, arterial blood gases are abnormal. The kidneys 444 C H A P T E R 9 Diseases and Conditions of the Respiratory System Nasal cavity Nasopharynx Oropharynx Pharynx Upper respiratory tract Laryngopharynx Larynx Trachea Left and right primary bronchi Lower respiratory tract Alveolar duct Alveoli Bronchioles Bronchioles Capillary S R L I Alveolar sac Figure 9-1 Structural plan of the respiratory system. (From Patton KT, Thibodeau GA: The human body in health & disease, ed 6, Maryland Heights, MO, 2014, Elsevier.) work to adjust bicarbonate in the blood in response respiratory tract, which includes the nose, pharynx, to carbon dioxide. larynx, and trachea (Figure 9-1). In the lungs, oxygen inhaled from the air is In the chest, the trachea bifurcates into the bronchi. exchanged with carbon dioxide from the blood; this Each bronchus enters a lung, where it further divides process is called external respiration. Internal respiration into increasingly smaller air passages called bronchioles. refers to the exchange of gases between the blood and At the end of each bronchiole is a saclike cavity called tissue cells. Carbon dioxide then is exhaled as a waste an alveolus. There are approximately 300 million product. Inhaled and exhaled air passes through the alveoli in each lung. The vital exchange of carbon  CHAPTER 9 Diseases and Conditions of the Respiratory System 444.e1 External Respiration Alveolus CO2 O2 Capillary lumen Red blood cell Capillary endothelium Pulmonary circulation Systemic circulation Heart E9-1 Mechanism of respiration. (From Bonewit-West: Clinical Procedures for Medical Assistants, ed 9, St. Louis, 2015, Saunders.)  CHAPTER 9 Diseases and Conditions of the Respiratory System 445 Inspiration Expiration Chest cavity Chest cavity expands becomes smaller Figure 9-2 Diaphragm and chest movement on inspiration and expiration. dioxide for oxygen takes place through capillaries that between the pleurae, preventing friction and allowing lie next to the walls of the alveolus. the pleurae to slide easily on each other. Between the A muscular, dome-shaped partition called the dia- lungs is the mediastinum, where the heart, great phragm attaches to the lower ribs and separates the vessels, trachea, esophagus, and lymph nodes are thoracic cavity from the abdominal cavity. On inspira- located. tion, the diaphragm contracts, pulling downward and Respiratory failure can result from the impairment causing air to be sucked into the lungs. During expira- of alveolar-arterial gas exchange (hypoxia), which tion, the diaphragm relaxes, pushing upward and results in a decrease of oxygen in the blood. Addition- forcing air out of the lungs (Figure 9-2). Expansion of ally, respiratory failure can be caused by the inability the chest cavity and diaphragmatic contraction are to ventilate, which results in an increasing buildup of active, energy-requiring processes. Exhalation occurs carbon dioxide. Diseases of the respiratory system as the stretched chest cavity springs back to its resting result from infection, circulatory disorders, tumors, state along with the relaxation of the diaphragm. This trauma, immune diseases, congenital defects, central is a passive process. nervous system damage or diseases, inflammatory dis- The membrane called the visceral pleura encases the turbances, or environmental conditions. lungs, and the parietal pleura line the inside of the Chief symptoms indicating respiratory tract disor- chest or thoracic cavity. The potential space between ders that should receive medical attention include: the visceral and parietal pleura is called the pleural Chest pain cavity. Depending on the body size, approximately 10 Dyspnea (difficulty in breathing), shortness of to 20 ml of pleural fluid is contained in the space breath 446 C H A P T E R 9 Diseases and Conditions of the Respiratory System Productive or nonproductive cough that is acute or severe headache, stiff neck, decreased urine, or other chronic complications indicate the need for medical care Hemoptysis (spitting up blood) within 24 hours. Dysphonia (hoarseness) Chills Etiology Low- or high-grade fever The common cold is a group of minor illnesses that Wheezing can be caused by almost 200 different viruses. Cold Fatigue viruses are not part of normal body flora, thus viruses that cause a cold are passed from one human to another. Colds are frequent diseases and a common Common Cold/Upper Respiratory cause of absenteeism from work and school. Rhinovi- Tract Infection ruses cause about one half of the colds in adults. (Some colds may result from mycoplasma and other Description atypical organisms that are more like bacteria than The common cold, also referred to as an upper respira- viruses. These are also transmitted by airborne tory infection (URI), is an acute inflammatory process respiratory droplets.) Viral infections sometimes are that affects the mucous membrane that lines the upper followed by bacterial infections of the pharynx, middle respiratory tract. ear (see the Otitis Media section in Chapter 5), sinuses, larynx, or lungs. General poor health, lack of ICD-9-CM Code 460 exercise, and poor nutrition predispose one to the ICD-10-CM Code J00 (Acute nasopharyngitis [common cold]) common cold. Symptoms and Signs Diagnosis Although the common, or “head,” cold is confined to Diagnosis is made from the symptoms described by the nose and pharynx, the same viruses can infect the the patient. To rule out a more serious disease, cultures larynx (see the Laryngitis section) and various areas of of the nasal discharge and sputum, along with a com- the lungs (see the Acute and Chronic Bronchitis plete blood count (CBC), may be needed. section). The suffix “-itis” is added to the anatomical location where most of the inflammation is occurring Treatment (i.e., pharyngitis, laryngitis, tracheitis, or bronchitis). An ordinary cold should clear up in 4 or 5 days, and The symptoms of a cold tend to be subjective, and to a bacterial infection should resolve in no longer than some extent, depend on which virus is responsible; 7 to 10 days. Persistent cough or nasal congestion they include nasal congestion and discharge, sneezing, may suggest the presence of another process such watering eyes, sore throat, hoarseness of the voice, and as allergies or asthma. There is no cure for a cold. coughing. When this highly contagious inflammatory Resting, drinking plenty of fluids, using a vaporizer, process first begins, nasal discharge is usually clear and and taking over-the-counter antihistamines, decon- thin. In the adult, the symptoms usually abate in 5 to gestants, cough suppressants, and mild analgesics can 7 days without antibiotic therapy. In some cases, the give temporary relief of symptoms. cold progresses and the discharge becomes greenish yellow and thick. Headache, slight fever, and chills NOTE often accompany a cold. A high fever and malaise, however, are more likely to be symptoms of influenza Aspirin is contraindicated for infants and children; (see the Influenza section). acetaminophen is the drug of choice. Patient Screening Mechanism of Action Symptoms of a cold that are prolonged or accompa- Antihistamines are drugs that inhibit the action of or nied by fever, chest pain, chest congestion, earache, inhibit the formation of histamine in the body.  CHAPTER 9 Diseases and Conditions of the Respiratory System 447 Antihistamines help dry up nasal secretions, diminish common cold. Instruct the patient to avoid overuse of itchy or watery eyes, and decrease flare from allergic drugs, such as nasal sprays, and to take all medications reactions. Antihistamines may cause drowsiness. only as instructed. List the warning signs of complica- Decongestants are drugs that stimulate adrenergic tions that should be reported to the health care pro- receptors, which induces vasoconstriction of blood vider (i.e., shortness of breath, severe headache, chest vessels in the nose, throat, and sinuses. Stimulation of pain, high fever, and symptoms of dehydration or the α-adrenergic receptors decreases the swelling of stiff neck). the nasal tissue and reduces mucus formation. Expectorants (mucolytics) are medications that help dissolve mucus and reduce the viscosity of mucus Sinusitis secretions. Cough suppressants are medications used to treat or Description lessen cough. The efficacy of these drugs is question- Sinusitis is acute or chronic inflammation of the able. Cough suppressants are no longer recommended mucous membranes of the paranasal sinuses. for children less than 6 years old. ICD-9-CM Code 461.9 (Acute, unspecified) Antibiotics are of little value in treating viral infec- 473.9 (Unspecified sinusitis, tions; however, patients with recurring attacks of chronic) bronchitis (see the Acute and Chronic Bronchitis ICD-10-CM Code J01.90 (Acute sinusitis, section) or frequent middle ear infections may receive unspecified) some protection against these bacteria-caused compli- (J01.90-J01.91 = 2 codes cations by taking antibiotics. There is some data to of specificity) suggest that taking zinc lozenges may slightly shorten J32.9 (Chronic sinusitis, the course of the common cold. unspecified) (J32.0-J32.9 = 7 codes of Prognosis specificity) Sinusitis is classified by location, type, and extent The common cold is usually benign and self-limiting. of pathology. Refer to the physician’s diagnosis Patients who are immunocompromised may be more and then to the current editions of the ICD-9-CM vulnerable to developing frequent colds and complica- and ICD-10-CM coding manuals for greatest tions. Possible complications can include secondary specificity. bacterial infections as listed previously under the “Eti- ology” section. Symptoms and Signs Prevention The sinuses, cavities behind the facial bones that shape The mechanisms of the transmission of cold viruses the nose, cheeks, and eye sockets, are normally air are not always clearly defined. Because, in many cases, filled. In sinusitis, the frontal sinuses (located in the the mode of transmission is airborne respiratory forehead above the eyes) and the maxillary sinuses droplets and hand-to-hand contact, prevention is (located under the maxillary bones in the face) are the difficult. most commonly involved sinuses (Figure 9-3). When the frontal sinuses are affected, a headache is common Patient Teaching over one or both eyes, especially upon waking in the Colds are more common in children than adults and morning. Pain and tenderness, felt just above the eyes are a frequent cause of absenteeism. Once infected and that usually intensifies when bending over, are children can easily transmit new strains to family also common symptoms. Pain in the cheeks and upper members. Frequent, thorough hand washing and iso- teeth is a symptom of sinusitis in the maxillary sinuses. lation during the acute stage of illness are common If present, drainage will be a thick and greenish yellow sense measures that can help control transmission. mucopurulent discharge. The course of acute sinusitis Stress to the patient that antibiotics do not cure the is 3 to 4 weeks. 448 C H A P T E R 9 Diseases and Conditions of the Respiratory System Chronic sinusitis Acute sinusitis Secondary bacterial infection Frontal sinus Ethmoid sinus Acute rhinitis Allergic Eustachian tube Viral to middle ear Maxillary sinus Pharyngitis Otitis Tonsillitis media Laryngitis Acute tracheobronchitis Figure 9-3 Sinusitis. (From Damjanov I: Pathology for the health-related professions, ed 4, St Louis, 2011, Saunders/Elsevier.) (CT) scanning, and endoscopic sinoscopy. Sinuses Patient Screening that are air filled appear as dark patches on a radio- Individuals with symptoms of acute sinusitis (fever, graphic film, whereas fluid-filled sinuses appear as sinus congestion, facial tenderness and pain, and white areas. Bedside transillumination can suggest the severe headache) are encouraged to seek medical atten- presence of sinusitis. Additionally, a specimen of nasal tion as soon as possible. secretions may be taken for culture to identify or rule out bacterial agents. Etiology Sinusitis can be caused by viral, fungal, or, more com- Treatment monly, bacterial infections that travel to the sinuses Treatment of sinusitis can include saline nasal spray, from the nose, often after the patient has been infected corticosteroid nasal sprays, broad-spectrum antibiot- by a common cold. This occurs easily because the ics, oral corticosteroids, antihistamines, and deconges- mucous membranes that line the nasal cavity extend tants. Decongestants alleviate symptoms by shrinking into and also line the sinuses. One is predisposed to the swollen mucous membranes and drying up the sinusitis by any condition that blocks sinus drainage nasal discharge to expand the airway and ease breath- and ventilation (e.g., a deviated nasal septum or nasal ing. Oral and topical corticosteroids decrease the polyps). Sinusitis also may result because of swimming inflammation of the affected area and decrease the or diving, tooth extractions, tooth abscess, or allergies sensitivity to aggravating stimuli. Oral antibiotics are that affect the nasal passages. The cause of chronic used in the presence of bacterial infection and may sinusitis may never be determined; however, common include amoxicillin, doxycycline, sulfamethoxazole- variable immunodeficiency disease may be involved trimethoprim, or cephalosporins. Other antibiotics (see Chapter 3). may be used depending on the infecting organism. Determination of allergic sinusitis may include allergy Diagnosis testing followed by appropriate desensitization with The diagnosis of sinusitis is made by evaluating the immunotherapy and corticosteroids. If the inflamma- findings of a physical examination, patient history, tion persists, a minor surgery called sinusotomy may sinus radiographic studies, computed tomography be advised by the physician. With the patient under  CHAPTER 9 Diseases and Conditions of the Respiratory System 449 local anesthesia, the physician pierces the maxillary be red and swollen with or without tonsillar exudate, sinus, allowing drainage and relief of pressure. Often depending on the causative organism. the physician instills sterile water into the sinus to flush out any residual material. Analgesics are usually Patient Screening given for pain relief. An individual complaining of a persistent sore throat with systemic symptoms should be seen by a physician Prognosis within 24 hours. Advise the patient not to initiate The prognosis for uncomplicated acute sinusitis is antibiotic therapy before the appointment because good. Chronic sinusitis can require more prolonged this can preclude accurate diagnostic testing. medical treatment with antibiotics. Etiology Prevention The most common cause of pharyngitis is a viral infec- Management of conditions that predispose an indi- tion; tonsillitis is the most important cause. In children, vidual to sinusitis may help prevent chronic sinusitis. it is often an extension of a bacterial streptococcal infec- tion from the tonsils, adenoids, nose, or sinuses. Persis- Patient Teaching tent infection, or chronic pharyngitis, occurs when an Use visual aids to explain the sinus cavities and their infection (respiratory, sinus, or oral disease) spreads to function. Explain the importance of complying with the pharynx and remains. Acute pharyngitis may be the treatment plan and returning for follow-up secondary to systemic viral infections, such as chicken- appointments. List the warning signs of complica- pox and measles, whereas chronic pharyngitis may tions, such as chills, fever, facial edema, severe head- accompany diseases, such as syphilis and tuberculosis ache, stiff neck, lethargy, or confusion. Prepare the (TB). Gonococcal pharyngitis may result from oral- patient for diagnostic testing or surgery by explaining genital sexual activity with an infected partner. Pharyn- each procedure and what to expect in terms of prepa- gitis also can be caused by irritation and inflammation ration and care afterward. without infection. Occasionally, inhalation or swallow- ing of irritating substances, such as tobacco smoke and Pharyngitis alcohol, is responsible for trauma to the mucous mem- branes of the pharynx. Breathing in excessively heated Description air or chemical irritants and swallowing sharp objects Pharyngitis (sore throat) is acute or chronic inflam- (e.g., a large ice chip or hard candy) also can cause mation or infection of the pharynx. trauma. Seasonal allergies may induce pharyngitis. ICD-9-CM Code 462 Diagnosis ICD-10-CM Code J02.9 (Acute pharyngitis, unspecified) Physical examination usually shows red, swollen (J02.0-J02.9 = 3 codes mucous membranes. Along with patient history, this of specificity) is usually sufficient for determining the diagnosis of acute pharyngitis. For chronic pharyngitis, the physi- cian needs to identify and locate the primary source Symptoms and Signs of the infection or irritation. Further examination of Pharyngitis may be acute or chronic and often involves the nasopharyngeal area, a CBC, and sinus radio- inflammation of the tonsils, uvula, and palate. A sore graphic films may be necessary. throat with dryness, a burning sensation, or the sensa- tion of a lump in the throat is common. Clinical Treatment manifestations vary with the type of pharyngitis. Gen- Home treatment using lozenges, mouthwashes, salt erally chills, fever, dysphonia, dysphagia, and cervical water gargles, an ice collar, and antiinflammatory lymphadenopathy are common. Upon examination medication may be helpful for viral infections. When of the throat, the mucosa of the pharynx is found to symptoms persist for longer than a few days, a 450 C H A P T E R 9 Diseases and Conditions of the Respiratory System physician should be consulted. Because most cases Nasopharyngeal Carcinoma of pharyngitis are viral in origin, antibiotics are not prescribed. However, acute bacterial infections Description necessitate systemic administration of antibiotics or Nasopharyngeal tumors arise in the area of the pharynx sulfonamides. Documented streptococcal pharyngitis that opens into the nasal cavity anteriorly and the is treated with a 7- to 10-day course of antibiotics. oropharynx inferiorly. They are unique among head Chronic tonsillitis, adenoiditis, and adenoid hyper­ and neck cancers in that they are not as strongly linked trophy may be treated by surgical excision. Bed rest to tobacco use. Instead, they are often linked to dietary and copious amounts of fluids may be advised. intake or Epstein-Barr virus (EBV) infection. ICD-9-CM Code NOTE Neoplasms are coded by such known factors as Aspirin is not given to children because of the threat anatomic site, behavior, and nature (morphology). of Reye syndrome. Greatest specificity is obtained by referring to the physician’s diagnosis and then to the current edition of the ICD-9-CM coding manual. Prognosis ICD-10-CM Code C11.9 (Malignant neoplasm Uncomplicated pharyngitis resolves within a few days. of nasopharynx, Bacterial causes are cured with appropriate antibiotics. unspecified) Chronic cases may require eliminating the underlying (C11.0-C11.9 = 6 codes of cause, such as smoking or allergens, before improve- specificity) ment can be achieved. Symptoms and Signs Prevention Because of the anatomic location of the nasopharyn- Prevention measures include maintaining general geal tumor, patients are often asymptomatic during good health, avoiding infections, evading known irri- the early stages of the disease. The classic clinical triad tants, and controlling allergies. of symptoms is neck mass, nasal obstruction with epistaxis, and serous otitis media. Although it is rare Patient Teaching to find all three symptoms in a single patient, the Instruct the patient to take the entire course of anti- individual symptoms occur frequently. Other symp- biotic therapy and keep follow-up appointments to toms include headache, hearing loss, tinnitus, pain, ensure a cure and help prevent complications. Provide and impaired function of the cranial nerves. a list of comfort measures, such as safe use of analge- sics, warm saline gargles, adequate fluid intake, and a Patient Screening soft diet. Advise patients with chronic pharyngitis to Provide the first available appointment to the indi- stop smoking; refer them to a support group. vidual reporting neck mass or related symptoms. Etiology NOTE Although nasopharyngeal carcinoma is a rare disease A more serious condition may appear initially as a in the United States and Western Europe, several routine pharyngitis. Ludwig angina involves a cellulitis populations do have a relatively high incidence. These on the floor of the mouth, whereas epiglottitis include people from southern China, areas around the involves an infection of the structure overlying the voice box (larynx). Both are often characterized by Mediterranean Sea, Southeast Asia, and the Arctic. It fever and severe sore throat. However, drooling, is two to three times more common in males than difficulty breathing, and inability to swallow may females and has peak incidence in persons between the occur and indicate some compromise to the ages of 10 and 25 or 50 and 60. Several known risk respiratory tract. Patients should seek emergency factors in the high-risk areas include consumption of medical attention if these symptoms develop. salted fish as a diet standard, foods with high levels of  CHAPTER 9 Diseases and Conditions of the Respiratory System 451 nitrates (such as processed meats), and Chinese herbs; nasopharyngeal carcinoma is not currently performed infection with the EBV; and having a first-degree rela- except in southern China where the disease is most tive with nasopharyngeal carcinoma. Use of alcohol prevalent. and tobacco is a risk factor in low-risk areas. Patient Teaching Diagnosis Prepare the patient for diagnostic testing by providing Diagnosis is made following a full clinical examina- information about endoscopy of the nasopharynx and tion of the head and neck and an endoscopic examina- biopsy of any lesion in the nasopharynx. Tell the tion of the nasopharynx with biopsy of suspicious patient when to expect results. After diagnosis, explain lesions. Testing for EBV should also be performed. the treatment of choice and possible side effects. Staging is determined according to the Tumor, Node, Encourage the patient to ask questions, and defer to Metastasis (TNM) system, in which T reflects the the physician for prognosis. Provide information extent of tumor invasion into adjacent structures and regarding cancer support groups. N incorporates lymph node location, as well as size. A magnetic resonance imaging (MRI) scan of the head and neck, a bone scan, and a CT scan or positron Laryngitis emission tomography (PET) scan are used to aid in staging. See Chapter 1 for information about the Description staging and grading systems used to assess malignant Inflammation of the larynx (hoarseness), including neoplasm. the vocal cords, is called laryngitis. Treatment ICD-9-CM Code 464 ICD-10-CM Code J04.0 (Acute laryngitis) Because of the anatomic constraints of the nasophar- Laryngitis coding includes modifiers that specify ynx, surgery is usually not performed. Nasopharyn- causative agents and factors, such as geal carcinoma commonly is quite radiosensitive, and obstruction. Refer to the physician’s diagnosis most patients with early stage cancer are treated with and then to the current editions of the ICD-9-CM radiation therapy with or without adjuvant chemo- and ICD-10-CM coding manuals for the therapy. Those with recurrent or more advanced car- appropriate modifiers. cinomas are generally treated with chemoradiotherapy. Patients should have close follow-up after completion of therapy to assess for recurrence. Symptoms and Signs Because the opening of the larynx is narrow, Prognosis inflammation of the larynx sometimes interferes with Because early neoplasms rarely cause symptoms, most breathing. Symptoms vary with the severity of the patients have advanced carcinoma, and many already inflammation, but the main symptom of laryngitis is have distant metastases to the bone, lung, or liver. If hoarseness, which causes aphonia. Fever, malaise, a the tumor has extended to involve one of the cranial painful throat, dysphagia, and other symptoms associ- nerves or has metastasized to the cervical lymph nodes, ated with influenza occur in more severe infections. the prognosis is worse. In addition, the presence of high plasma levels of EBV DNA at the time of diag- Patient Screening nosis or following treatment can correlate with a Laryngitis associated with recent trauma requires poorer outcome. immediate medical attention. A sensation of swelling in the throat, difficult breathing, and laryngitis is to Prevention be considered a medical emergency. An individual It is possible to detect circulating EBV DNA in reporting persistent hoarseness and symptoms of the serum of affected individuals. Still, screening infection should be seen in the medical office within for EBV in first-degree relatives of patients with 24 hours. 452 C H A P T E R 9 Diseases and Conditions of the Respiratory System Etiology Patient Teaching The cause of laryngitis can be either viral or bacterial Explain the importance of resting the voice and taking infection, and the condition can be either chronic or medications as prescribed, along with drinking plenty acute. URIs such as the common cold, tonsillitis, phar- of fluids. When the cause of chronic laryngitis has yngitis, and sinusitis are the most common causes of been determined to be irritation from excessive alcohol inflammation of the larynx. Laryngitis also occurs with intake or smoking, provide information on support bronchitis, pertussis, influenza, pneumonia, measles, groups that offer help to those with such addictions if mononucleosis, diphtheria, syphilis, and TB. Occa- appropriate. sionally laryngitis is caused by irritation without infec- tion. Reflux laryngitis may result from repeated attacks Deviated Septum of acid reflux. Inclement weather, tobacco smoke, alcohol consumption, inhalation of irritating materi- Description als, and excessive use of the voice are all predisposing A crooked nasal septum (the cartilage partition factors, especially in the case of chronic laryngitis. between the nostrils) is called a deviated septum Hoarseness can also be caused by benign or malignant (Figure 9-4). lesions of the larynx. In most cases the pathology is ICD-9-CM Code 470 (Acquired) benign, but malignancy must be ruled out. ICD-10-CM Code J34.2 (Deviated nasal septum) Diagnosis Laryngoscopic examination reveals mildly or highly Symptoms and Signs inflamed mucosa, and vocal cord movement may be A deviated septum causes narrowing and obstruction limited. If no inflammation is present, laryngitis is not of the air passage, making breathing somewhat diffi- the cause of dysphonia, and further diagnostic tests cult. Other than mild breathing problems or a slightly are needed to determine the underlying condition. increased tendency to develop sinusitis, no significant symptoms are associated with a deviated septum. The Treatment nose can appear normal on the exterior, with the Treatment of viral laryngitis includes the following deviation visible only on examination with a nasal palliative measures: absolute voice rest, bed rest in a speculum. well-humidified room, liberal fluid intake, no tobacco or alcohol consumption, and the use of lozenges and Patient Screening cough syrup. Improvement should be seen in 4 or 5 Unless the deviated septum is severe, it may not be days. Antibiotic administration gives good results noted until inadvertently found as a consequence of a when laryngitis occurs in conjunction with bacterial infection. Corticosteroids may be used to decrease inflammation when symptoms are more severe. When hoarseness persists for longer than 1 week, the condi- tion may be chronic. Treatment of chronic laryngitis is based on elimination, as much as possible, of the causative factors. Prognosis Recovery is generally complete within 1 week. Prevention Figure 9-4 Deviated septum. (From Monahan FD, Neigh- Known irritants that cause laryngitis are avoided or bors M: Medical-surgical nursing: foundations for clinical treated if possible. Infections are difficult to prevent. practice, ed 2, Philadelphia, 1998, Saunders.)  CHAPTER 9 Diseases and Conditions of the Respiratory System 453 routine physical examination. The condition may be of no consequence until aggravated by trauma to the nose. In that case, schedule the first available appoint- ment for evaluation. Etiology Congenital anomaly is usually the cause of minor deviation of the septum. Substantial septal deviation is uncommon and is usually the result of trauma to the nose. Diagnosis Figure 9-5 Nasal polyps. (From Lemmi FO, Lemmi CAE: A deviated septum may not be visible without the Physical assessment findings CD-ROM, Philadelphia, 2000, aid of a nasal speculum. The patient history and Saunders.) the amount of obstruction aid the physician in determining the diagnosis and treatment of this condition. ICD-9-CM Code 471.9 (Unspecified) ICD-10-CM Code J33.9 (Nasal polyp, Treatment unspecified) Treatment is not usually necessary unless compromise (J33.0-33.9 = 4 codes of the air passage is noted. The septum can be straight- of specificity) Nasal polyps are coded by anatomic site and ened surgically to repair a significant obstruction or underlying pathology. Refer to the physician’s for cosmetic reasons. Straightening a deviated septum diagnosis and then to the current editions of the involves removing the cartilage (rhinoplasty or septo- ICD-9-CM and ICD-10-CM coding manuals for plasty). Once removed, the cartilage can be reshaped greatest specificity. and repositioned in the nose if needed to maintain the nasal structure. Symptoms and Signs Prognosis Nasal polyps are not harmful but can become large This fairly common condition has a good prognosis. enough to obstruct the nasal airway, making breathing difficult. Polyps often affect or impair the sense of Prevention smell (see the Anosmia section). When polyps obstruct The only possible prevention is avoiding trauma to the one of the sinuses, symptoms of sinusitis are present nose. (see the Sinusitis section). Patient Teaching Patient Screening If surgical correction is scheduled, tell the patient what Nasal polyps may be found in the patient exhibiting to expect after surgery, such as the use of nasal packing symptoms of allergic rhinitis and/or sinusitis. The to control bleeding and analgesics for pain. degree of urgency for an appointment is based on severity of symptoms. Nasal Polyps Etiology Polyps are caused by the overproduction of fluid in Description the cells of the mucous membrane. This overproduc- Nasal polyps are benign growths that form as a con- tion is often the result of a condition called allergic sequence of distended mucous membranes protruding rhinitis. Some aspirin-sensitive persons have the triad into the nasal cavity (Figure 9-5). of nasal polyps, asthma, and urticaria (hives). 454 C H A P T E R 9 Diseases and Conditions of the Respiratory System Diagnosis Patient Screening The physician examines the inside of the nose using The patient complaining of prolonged, unexplained an instrument called a nasal speculum. Polyps appear loss of the sense of smell is scheduled for a diagnostic as pearly gray lumps along the nasal passage. evaluation. Treatment Etiology Surgical removal is the treatment of choice; however, A chronic condition, such as nasal polyps and allergic considerable relief may be obtained through the injec- rhinitis, is the most common cause of anosmia. tion of a steroid directly into the polyps. This proce- Intranasal swelling accompanying an upper respira- dure is repeated at 5- to 7-day intervals until relief is tory condition causes temporary anosmia. Sometimes obtained. Removal of polyps is a minor procedure a phobia concerning a particular odor accounts necessitating a local anesthetic. Rhinoplasty may also for a psychologic basis for anosmia. It may, however, be indicated. When the lining of the sinus also must be the result of damage to the olfactory nerves caused be removed, a general anesthetic is used. by a head injury or, rarely, a symptom of a brain tumor. Prognosis The prognosis is good, although nasal polyps tend to Diagnosis recur. If on examination the physician does not find any physical abnormality or the patient history does not Prevention reveal recent head trauma or an allergic condition, a No specific preventive measures are known. Manage- neurologist may be consulted to perform diagnostic ment of allergic rhinitis is beneficial. tests. Patient Teaching Treatment Instructions given to the patient are related to the Treatment is aimed at the cause of the condition. treatment of choice. When appropriate, explain the When polyps are found, they are removed. Correction relationship of allergic rhinitis to nasal polyps. of nerve damage may not be possible. For allergic rhinitis, a series of injections containing increasingly stronger concentrations of the offending allergen is Anosmia. used to desensitize the patient. Description Prognosis Anosmia is the impairment or loss of the sense of Anosmia is often related to a URI and is thus a tem- smell. porary condition. Other causes, as listed earlier, have a guarded prognosis. ICD-9-CM Code 781.1 (Requires fifth digit) ICD-10-CM Code R43.0 (Anosmia) Prevention R43.1 (Parosmia) R43.2 (Parageusia) No means of prevention other than avoiding head (R43.0-R43.9 = 5 codes of injury is known. specificity) Patient Teaching Patients may benefit from an explanation of how Symptoms and Signs the olfactory nerve normally functions and how The loss of smell that continues without an obvious it is affected by the determined cause of anosmia. cause is termed anosmia. The ability to taste liquids (Figure 1-9 illustrates the structure of the olfactory and food also is impaired or lost. nerve.)  CHAPTER 9 Diseases and Conditions of the Respiratory System 455 Epistaxis (Nosebleed) Diagnosis Description The diagnosis of epistaxis is made on the basis of the Epistaxis is hemorrhage from the nose. patient history regarding the frequency of the nose- bleeds, whether an injury has occurred, or whether the ICD-9-CM Code 784.7 symptoms indicate that systemic disease may be ICD-10-CM Code R04.0 (Epistaxis) present. All medications, dietary supplements, and herbal preparations taken by the patient are noted to Symptoms and Signs help identify contributing offenders. Hemorrhage from the nose, known as epistaxis, is a common, sudden emergency. Bleeding usually occurs Treatment from only one nostril, and often no apparent explana- First the severity of blood loss is assessed. Mild hemor- tion for the bleeding is known. Most nosebleeds are rhage may be controlled by applying constant direct seldom a cause for concern. They are unlikely to be a pressure on either side of the bridge of the nose for 5 symptom of any other disorders, unless injury has to 10 minutes. An internal compression device, such occurred or associated serious systemic conditions are as RhinoRocket, may be used. Persistent bleeding is present. With significant blood loss, systemic symp- treated with local application of epinephrine followed toms will occur, such as vertigo, an increase in pulse, by cauterization with silver nitrate or laser cauteriza- pallor, shortness of breath, and drop in blood pressure. tion. If bleeding continues, a posterior nasal packing Epistaxis is more common in children than in adults. left in place for 1 to 3 days may be necessary. A mild sclerosing agent also may be injected into a bleeding Patient Screening vessel if it can be visualized by the physician. Addi- Hemorrhage from the nose that persists for 10 minutes tional measures, such as surgical ligation of a bleeding or more after constant pressure is applied is considered artery, may be necessary if other measures fail. severe and requires immediate emergency care. If the patient reports a severe headache at the onset of epi- Prognosis staxis, or is experiencing sequential nosebleeds, arrange The prognosis is generally good. for an immediate appointment. Prevention Etiology Specific treatment of the underlying disease, if present, Common causes of epistaxis are colds and infections, is of prime importance. Prevention includes instruct- such as rhinitis, sinusitis, and nasopharyngitis, which ing patients on how to avoid recurrences. can cause crusting that damages the mucous mem- brane lining the nose or the rupture of tiny vessels in Patient Teaching the anterior septum of the nose. Direct trauma to the Demonstrate first aid measures for controlling nose, picking the nose, and the presence of a foreign epistaxis—sitting with the head tilted forward while body are the most common causes of epistaxis. Nasal applying constant local pressure by compressing the hemorrhage also has been encountered in relation to side of the nose against the septum. Tell the patient many systemic disorders, such as measles, scarlet fever, to report repeated or severe nosebleed immediately to pertussis, rheumatic fever, hypertension, congestive the health care provider. Discuss measures for prevent- heart failure, and chronic renal disease. Epistaxis may ing recurrences. be the foremost symptom of conditions, such as hemophilia, thrombocytopenia, agranulocytosis, and Tumors of the Larynx leukemia. Risk factors include vitamin K deficiency, hypertension, aspirin ingestion, high altitude, and Description anticoagulant therapy. An infrequent cause of epistaxis Growths or tumors on the larynx may be benign or is extensive hepatic disease. malignant. 456 C H A P T E R 9 Diseases and Conditions of the Respiratory System True vocal cords (vocal folds) Normal larynx Polyp on left vocal cord Figure 9-6 Vocal cord polyp. ICD-9-CM Code 140-239 Etiology (Neoplasms) There are two types of benign tumors: papillomas, ICD-10-CM Code C00-D49 which usually appear as multiples, and polyps, which The above general codes represent the broad usually appear singly (Figure 9-6). These tumors are category of neoplasms that are classified by caused by misuse or overuse of the vocal cords, such diagnostic criteria as malignant or benign, although smoking and reflux are contributing factors. as primary or secondary, or according to site, Malignant tumors occur more often in those who function, and morphology. Refer to the indulge in heavy tobacco use. physician’s diagnosis and then to the current editions of the ICD-9-CM and ICD-10-CM coding Diagnosis manuals to ensure the greatest specificity of pathology. The physician or otolaryngologist thoroughly exam- ines the larynx and vocal cords. When a tumor or tumors are found, a biopsy is done to determine Symptoms and Signs whether a malignancy is present. Cancer of the larynx Dysphonia is usually the only symptom of a tumor almost always can be cured if it is diagnosed early. on the larynx. No influenza-like symptoms occur as with laryngitis (see the Laryngitis section), but when Treatment the tumor is malignant, dysphagia may be experi- Benign growths, whether papillomas or polyps, may enced. In children with tumors, a high-pitched be treated with correction of vocal strain, reflux man- crowing sound called stridor is present because of agement, and smoking cessation. They may also be their small airways. Hoarseness caused by a benign excised with the use of a local anesthetic. Malignant tumor is usually intermittent, whereas hoarseness tumors, if discovered early, often are treated and cured caused by cancer is continuous and gradually becomes by radiation therapy. When the cancer has metasta- worse. Neither type of laryngeal tumor is common, sized, a laryngectomy may be needed. After a laryn- but malignant tumors are slightly more common in gectomy, the patient needs extensive speech therapy men than women. to learn a substitute form of speech. Patient Screening Prognosis Unexplained, persistent hoarseness lasting longer than The prognosis depends on the type of tumor. 2 weeks requires medical evaluation. Other symptoms related to the throat also may be present. The appoint- Prevention ment can be made at the first available time or at the Avoidance of smoking or any chronic irritation of the patient’s first convenience. larynx is recommended.  CHAPTER 9 Diseases and Conditions of the Respiratory System 457 related to the throat also may be present. The appoint- Patient Teaching ment can be made at the first available time or at the Give the patient preoperative instructions and encour- patient’s earliest convenience. age the patient to express any concerns about treat- ment. When laryngectomy is necessary, provide every Etiology venue of psychological support available to the family The major risk factors for development of laryngeal and patient. Help the patient plan alternate means of cancer are smoking and alcohol abuse. The combined communication during speech rehabilitation. effect of alcohol and tobacco in causing cancer is multiplicative, leading heavy smokers and drinkers to Laryngeal Cancer have a 200-fold greater risk of developing laryngeal cancer than nonsmokers and nondrinkers. Other risk Description factors include infection with human papillomavirus Laryngeal cancer describes a neoplasm of the larynx, (HPV) 16 or 18, occupational exposures to agents, the part of the respiratory tract between the pharynx such as perchloroethylene (a dry cleaning agent) or and the trachea that houses the vocal cords. It is the asbestos, and having a first-degree relative with laryn- most common site for head and neck tumors. Most geal cancer. Tumors of the larynx have a peak inci- laryngeal tumors are squamous cell carcinomas. dence in the sixth and seventh decades of life. ICD-9-CM Code 161.9 (Larynx, unspecified) Diagnosis ICD-10-CM Code C32.9 (Malignant neoplasm of larynx, unspecified) Laryngeal cancer is often diagnosed at an earlier stage (C32.0-C32.9 = 6 codes of than other head and neck cancers because hoarseness specificity) usually occurs early in the disease process. Flexible The above code is a nonspecific code and may fiberoptic endoscopy allows visualization of the larynx be valid as a principal diagnosis, except for and assessment of vocal cord mobility. Diagnosis of Medicare. Refer to the physician’s diagnosis and cancer requires a biopsy, which is usually done by then to the current editions of the ICD-9-CM and fine-needle aspiration. Staging is done using a TNM ICD-10-CM coding manuals to ensure the system. A CT scan or MRI scan is performed to evalu- greatest specificity. ate depth and extent of tumor invasion and to look for nodal metastasis. A panendoscopy (laryngoscopy, Symptoms and Signs esophagoscopy, and bronchoscopy) is generally done If the tumor involves the vocal cord area of the larynx, as well to look for other areas of tumor growth because persistent hoarseness tends to occur early in the disease tobacco and alcohol use often have widespread toxic process and is the most common initial complaint. effects on the aerodigestive tract. A PET scan can be Hoarseness related to benign causes, such as a vocal done to look for distant metastases. See Chapter 1 for cord polyp or nodule caused by chronic irritation or information about the staging and grading systems overuse, is usually intermittent, whereas that caused by used to assess malignant neoplasm. a malignant neoplasm is continuous and gradually becomes worse over time. Other symptoms may Treatment include dysphagia, hemoptysis, chronic cough, referred The larynx plays an important role in speech, swallow- pain to the ear, and stridor (a high-pitched crowing ing, respiration, and protection of the lower airway. sound). Airway obstruction also may occur depending Therefore quality of life issues are often incorporated on the tumor location. No influenza-like symptoms as into the treatment plan. For early stage cancer, often with laryngitis are present (see the Laryngitis section). the physician will explain the risks and benefits of surgery and radiation therapy, both of which have a Patient Screening similar outcome, and let the patient decide on the Unexplained, persistent hoarseness lasting longer than therapy. Usually the patient will choose the option 2 weeks requires medical evaluation. Other symptoms that preserves voice—radiation. Surgical options 458 C H A P T E R 9 Diseases and Conditions of the Respiratory System include partial laryngectomy, total laryngectomy, and ICD-9-CM Code 786.3 endoscopic laser resection. The choice largely depends ICD-10-CM Code R04.2 (Hemoptysis) on tumor stage. Treatment of later stage (III and IV) P26.9 (Pulmonary cancers is more difficult. For patients with resectable hemorrhage originating in the tumors, treatment usually consists of surgery followed perinatal period) by radiation therapy or by radiation alone. Chemora- (P26.0-P26.9 = 4 codes diotherapy may be tried in patients choosing an of specificity) organ-sparing approach. For patients who do undergo A15.0 (Tuberculosis a laryngectomy, follow-up care generally requires the of lung) services of a speech therapist for speech therapy and A15.7 (Primary respiratory swallowing therapy. tuberculosis) Prognosis Because of the early manifestation of symptoms, Symptoms and Signs laryngeal cancer is often diagnosed at a stage in Sputum streaked or spotted with blood can be present which a cure is possible. The most significant prog- with minor infections. Hemoptysis can be massive, nostic indicator is the status of the cervical lymph indicating a serious underlying condition. The patient nodes. The overall 5-year survival rate ranges from expectorates bright or dark blood-streaked sputum or 30% to 90%, depending on the tumor stage at dark red clots from the pulmonary or bronchial cir- diagnosis. Patients with laryngeal cancer are more culation. Profuse bleeding is present in severe lung likely to develop second primary cancers than patients infections (i.e., aspergillus infection with angio inva- with malignancies outside the head and neck because sion), a respiratory malignancy, or erosion of a pul- of the widespread carcinogenic effects of tobacco and monary vessel. alcohol in the head and neck area. The development of another primary tumor often indicates a worse Patient Screening prognosis. Blood of unknown origin in the sputum is a symptom that requires medical evaluation. If the bleeding is Prevention slight and associated with a known respiratory infec- Cessation of smoking and reducing one’s alcohol con- tion, schedule an appointment within 24 hours. sumption are highly recommended. Periodic panen- Advise the patient experiencing profuse bleeding to doscopy may be used to detect second primary cancers seek emergency care, and inform the physician after treatment for laryngeal cancer. immediately. Patient Teaching Etiology Encourage the patient to express any concerns about Trauma, erosion of a vessel, calcification, or tumors diagnostic procedures or the course of treatment can cause bronchial bleeding, as can inflammatory chosen. Provide every venue of psychological support conditions, such as bronchitis or bronchiectasis; available to the patient and the family. Give specifics chronic infection can result in damaged and irreg- about the postoperative care of laryngectomy, as ularly shaped airways. Pulmonary arterial hyper- appropriate. Help the patient plan alternate means of tension (often associated with right-sided heart communication during speech rehabilitation. failure) and at times pulmonary venous hyperten- sion (associated with left-sided heart failure) may Hemoptysis precipitate bleeding from pulmonary vessels. Addi- tional origins of the bleeding can be fungal infec- Description tions, pulmonary infarcts, tumors or ulcerations of Hemoptysis is the coughing or spitting up of blood the larynx or pharynx, and coagulation (clotting) from the respiratory tract. defects.  CHAPTER 9 Diseases and Conditions of the Respiratory System 459 medical attention if the amount of hemoptysis signifi- Diagnosis cantly increases. Of primary importance is determination of the source of the bleeding. This is accomplished by visual Atelectasis examination of the mouth and nasopharynx; visual- ization of the larynx, trachea, and bronchi by endos- Description copy; and inspection of the lung fields by radiographic Atelectasis is an airless or collapsed state of the pul- studies. Pulmonary angiogram can be used for diag- monary tissue. nosis and therapeutic embolization. ICD-9-CM Code 518.0 Coagulation studies of the blood ascertain whether ICD-10-CM Code J98.11 (Atelectasis) the problem is a clotting deficiency. The patient is J98.19 (Other pulmonary given a purified protein derivative (PPD) skin test to collapse) screen for TB. A lung scan, CT scan of the chest, and/ or pulmonary angiogram may be indicated if previ- ously mentioned investigations are inconclusive. Symptoms and Signs Atelectasis follows incomplete expansion of lobules or Treatment segments of the lung, with partial or complete collapse After the location and the cause of the bleeding of the lung. The condition results in hypoxia, causing are determined, the source is treated. When the bleed- the patient to experience dyspnea. When only a small ing is severe, ligation or surgical removal or repair segment of the lung is involved, dyspnea may be the of the involved vessels is indicated. Measures are only clinical symptom. When a large area of the pul- implemented to prevent asphyxiation by clotted monary tissue is involved, the area available for gas blood in the air passages; to prevent obstruction of the exchange is decreased, and the dyspnea becomes bronchial tree by clots, with resulting lung collapse; severe. Substernal retraction and cyanosis may be seen and to prevent exsanguination of the patient. on physical examination, and diminished breath If minor bleeding occurs or the cause is uncertain, sounds over the affected area are noted upon ausculta- antibiotics and cough suppressant therapy are often tion. Radiographic chest films may indicate a medias- prescribed. tinal shift toward the side of collapse. Additionally, the patient experiences anxiety, diaphoresis, and tachycar- Prognosis dia. Fever may be present because collapsed lung tissue Figures may vary; however, in approximately 75% of is prone to infection. Atelectasis also can occur with cases, hemoptysis is not a sign of serious disease. The incomplete expansion of the lungs at birth. prognosis is good with treatment, but guarded if asso- ciated with a serious underlying illness. Patient Screening The patient experiencing dyspnea requires prompt Prevention medical attention for evaluation. Severe dyspnea with Hemoptysis is generally considered a symptom, so or without a history of previous atelectasis is a medical there is no directed prevention. emergency; instruct the patient to call an ambulance. The physician should be notified immediately. Patient Teaching Steps are taken to allay fear and anxiety that the Etiology patient might experience. Explain the diagnostic pro- Atelectasis is caused by an obstruction in the bronchial cedures and when to expect the results. Reassure the tree; this can be a mucous plug, foreign body, or patient that hemoptysis may be expected following bronchogenic cancer. Compression atelectasis results endoscopy. Reinforce the treatment regimen and when a tumor exerts pressure on the lung and does encourage the patient to voice concerns. It is also not allow air to enter that part. Inflammatory pulmo- necessary to advise the patient to emergently seek nary disease can result in accumulation of fluid in the 460 C H A P T E R 9 Diseases and Conditions of the Respiratory System pleural cavity (pleural effusion) and induce atelectasis. Any condition that makes deep breathing difficult can Prevention lead to atelectasis (Figure 9-7). Failure to breathe Early ambulation and good ventilation therapy, after deeply postoperatively, or prolonged inactivity, also surgery or for any condition that causes prolonged can induce the collapse of pulmonary tissue. In the immobility, are important. Individuals with lung newborn, causes include prematurity, hyaline mem- disease are strongly advised not to smoke. brane disease, decreased stimulus to breathe, narcotics that cross the placental barrier during labor, and Patient Teaching obstruction of the bronchus by a mucous plug. Any Discuss the diagnostic and therapeutic procedures. condition that decreases the amount of surfactant (a Use visual aids depicting the respiratory system to lubricating fluid in the air sacs) can lead to collapse of explain atelectasis. Explain the importance of postop- these air sacs and hence atelectasis. erative ambulation and ventilation therapy. Tell the patient to seek prompt medical care for respiratory Diagnosis infections. Radiographic chest films, a thorough history, and physical examination play important roles in the diag- Pulmonary Embolism nosis. CT scans of the chest may be necessary to detect subtle changes. Breath sounds are diminished over the Description affected area, and percussion is dull. Bronchoscopy A pulmonary embolism occurs when a blood clot or may be indicated to evaluate obstruction by a foreign other material (e.g., foreign body or tumor) lodges in body or a neoplasm. and occludes an artery in the pulmonary circulation (Figure 9-8). Treatment ICD-9-CM Code 415.19 Because postoperative patients are at high risk for ICD-10-CM Code I26.99 (Other pulmonary atelectasis, they are encouraged to ambulate as soon embolism without as possible, breathe deeply, and cough periodically; acute cor pulmonale) an incentive spirometer is often used to encourage (I26.90-I26.99 = 3 codes deep breathing. Other therapeutic measures include of specificity) suctioning of the airway to remove any obstruction, spirometry, and the use of antibiotics to treat Symptoms and Signs accompanying infection. Analgesics are given for chest The size and location of the embolism, coupled with pain. Surgical drainage of pleural effusion (abnormal the general physical condition of the patient, deter- fluid accumulation in the intrapleural spaces of the mine the consequences of the interruption of blood lungs) may be indicated to reduce intrathoracic supply to the area and the resulting symptoms and pressure. signs. The most common symptom of acute pulmo- Suctioning the trachea of the newborn is indicated nary embolism is the sudden onset of dyspnea and to remove mucus and to facilitate a patent airway. chest pain when the embolism enters the pulmonary Suctioning usually is followed by the administration circulation and interrupts the blood flow. It should of oxygen. also be mentioned that pulmonary embolism is one of the masqueraders in medicine. It often presents Prognosis with non-respiratory symptoms, such as tachycardia. The outcome depends on treatment of the primary Apprehension is common. The patient with a small, cause. Mild cases may resolve spontaneously. More uncomplicated embolism experiences a cough, chest severe cases are prone to complications such as pneu- pain, and a low-grade fever. The patient with a more monia. Individuals with obesity, upper abdominal or extensive infarction experiences dyspnea, tachypnea chest surgery, neuromuscular weakness, or pulmonary (with a respiratory rate of at least 20 breaths per disease are at higher risk. minute), chest pain, and occasionally hemoptysis.  CHAPTER 9 Diseases and Conditions of the Respiratory System 461 Collapsed lung Pleural space filled with fluid Parietal pleura Separated Visceral pleura Mediastinal shift Pleural effusion External mass Compression atelectasis Atelectasis Obstruction in Air flow Remaining bronchus obstructed air diffuses into tissues and is not replaced Nonaeration and collapse Obstructive atelectasis – Absorption atelectasis Figure 9-7Atelectasis. (From Gould B: Pathophysiology for the health professions, ed 3, Philadelphia, 2006, Saunders.) 462 C H A P T E R 9 Diseases and Conditions of the Respiratory System Emboli Infarcted area B A Figure 9-8 Pulmonary embolism. (B, From Kumar V, Cotran R, Robbins S: Robbins basic pathology, ed 8, Philadelphia, 2008, Saunders.) Massive embolism leads to the sudden onset of cya- venous thrombosis. Oral contraceptives high in estro- nosis, shock, and death. gen, diabetes mellitus, and myocardial infarction are considered contributing factors. Patient Screening Pulmonary embolism may have symptoms that mimic Diagnosis a heart attack, with the onset of sudden chest pain and The clinical picture, along with a history of physical shortness of breath. He or she may be extremely immobility or other risk factors, leads to further inves- apprehensive. Instruct the patient to call an ambu- tigation of respiratory status. Lung scans and CT angi- lance and seek immediate emergency care. Notify the ography of the chest are used to image the pulmonary physician promptly. Individuals with milder symp- blood flow. Echocardiogram is also used to assess pul- toms of chest pain, fever, and dyspnea should be given monary artery pressure and right heart function. With prompt medical attention. current CT technology, pulmonary angiography, the definitive method of making the diagnosis, is rarely Etiology needed. Auscultation often reveals rales and pleural Although most emboli are thrombi (blood clots) that rub in the area of the embolism. Arterial blood gas have broken loose from a deep vein in the legs or determination shows reduced partial pressure of pelvis, emboli also may be composed of air, fat glob- oxygen and carbon dioxide. Studies performed to find ules, a small piece of tissue, or a cluster of bacteria. residual thrombi in the veins of the lower extremities The mass moves through the venous circulation and are helpful because the vast majority of pulmonary is pumped by the right side of the heart to the pul- emboli originate there. monary circulation, where it becomes lodged in a vessel, usually at a division of an artery where it Treatment narrows. Primary treatment is aimed at preventing a potentially Stasis of blood flow from immobility, injury to a fatal episode and maintaining cardiopulmonary integ- vessel, predisposition to clot formation, thrombophle- rity and adequate ventilation and perfusion. Oxygen bitis, cardiovascular disease, smoking, or pulmonary therapy and anticoagulant administration are used to disease increases the risk of embolism formation. In meet these goals. Heparin or its analogues are often pregnancy, multiple factors predispose individuals to used initially in the treatment because therapeutic  CHAPTER 9 Diseases and Conditions of the Respiratory System 462.e1 E9-2 Pulmonary embolism. (From Black: Medical-Surgical Nursing, ed 8, St. Louis, 2009, Saunders.)  CHAPTER 9 Diseases and Conditions of the Respiratory System 463 levels can be obtained quickly. Warfarin, an oral agent, ICD-9-CM Code 486 (Organism unspecified) is then used and maintained for weeks to months ICD-10-CM Code J18.9 (Pneumonia, depending on the clinical situation. Additionally, unspecified organism) when there are hemodynamic compromises (shock (J12.0-J18.9 = 29 codes of specificity) and right-sided heart failure) thrombolytic drugs sometimes are administered to dissolve a clot, espe- cially when low blood pressure or cardiac arrest Symptoms and Signs occurs. Pneumonia is not only a condition but also a general Prevention is important; most hospitalized patients term applied to several types of inflammation of the should be on some form of prophylactic therapy. lungs. The inflammation may be either unilateral or Early ambulation, low-dose anticoagulant agents, bilateral and involve all or only a portion of an infected and the use of a variety of stockings, such as throm- lung (Figure 9-9). The symptoms of pneumonia vary. boembolic disease (TED) stockings or sequential The patient may have a cough, fever, shortness of stockings that intermittently pump the legs, are breath even while at rest, chills, sweating, chest pains, employed as preventive measures for patients. cyanosis, and blood in the sputum. The infant or child exhibits “panting” or shallow, rapid respirations. The Prognosis larger the area of lung affected, the more severe the Mild cases can have a positive outcome with treat- symptoms are. How quickly the symptoms develop ment. Mortality is high in cases of massive pulmonary and which symptoms are most evident vary with the embolism. cause. Aspiration pneumonia results from aspiration of Prevention liquids or other material into the tracheobronchial Management of risk factors, such as long-term immo- tree. It tends to occur in patients who have serious bility, can prevent the formation of emboli that can problems with swallowing; it is commonly seen in the potentially obstruct pulmonary circulation. Postop- elderly, especially those weakened by cancer or those erative prophylactic measures are employed. Optimal with neurologic problems, such as stroke or Parkinson management of systemic diseases, such as myocardial disease. infarction, thrombophlebitis, and atrial fibrillation, is beneficial. Patient Teaching Use visual aids to demonstrate normal pulmonary circulation. Explain anticoagulation therapy and the importance of regular blood monitoring to ensure that therapeutic levels of the anticoagulant are being main- tained. Make the patient aware of side effects that should be reported to the health care provider, such as nosebleeds, blood in the stool, or spontaneous bruising under the skin. Explain the postsurgical pre- vention measures prescribed to prevent venostasis, such as antiembolism stockings. Pneumonia Figure 9-9 Appearance of pneumonia. (From Long BW, Description Frank ED, Ehrlich RA: Radiography essentials for limited Pneumonia is an infective inflammation of the lungs. practice, ed 4, St Louis, 2013, Elsevier.) 464 C H A P T E R 9 Diseases and Conditions of the Respiratory System scribed for bacterial pneumonia. Penicillin is the drug Patient Screening of choice for a pneumococcal pneumonia. Tetracy- Cough, fever, and shortness of breath are symptoms cline drugs, erythromycin, doxycycline, and sulfon- that require a prompt, same-day appointment for amides may be administered. Mycoplasma infections medical evaluation. Parents of infants may report that may be treated with broad-spectrum antibiotics. the child exhibits symptoms of a cold with fever and Fungal infections require the use of various antifungal fast respirations. The infant or child should be given medications, whereas viral infections are treated with top priority for a medical examination by a physician specific antiviral agents. The use of analgesics, such as within 2 hours. aspirin, helps to relieve chest pain, and oxygen therapy may be necessary for shortness of breath. Bed rest, Etiology increased fluid intake, a high-calorie diet, and postural Pneumonia usually is caused by viral or bacterial drainage also prove beneficial. infections. Organisms commonly causing bacterial pneumonia are pneumococci, staphylococci, group A Prognosis hemolytic streptococci, Haemophilus influenzae type The prognosis is good for otherwise healthy indi­ B, Klebsiella pneumoniae types 1 and 2, and other viduals. Severely or chronically ill patients are more gram-negative organisms. A syndrome referred to as predisposed to pneumonia. Pneumonia is the leading atypical pneumonia, previously referred to as walking cause of death worldwide and the eighth leading cause pneumonia, often demonstrates marked abnormalities of death in the United States. on the chest radiograph, yet the patient does not appear significantly ill. The organisms most com- Prevention monly identified with this syndrome include Legio- The pneumococcal vaccine is the only way to prevent nella, mycoplasma, and chlamydia agents. Viruses, such pneumococcal pneumonia. Vaccines are available for as adenoviruses, influenza viruses, and respiratory syn- adults, children, and certain groups. Anyone can cytial viruses (RSVs), also can produce pneumonia. contact their health care provider to find out if they It also may be caused by damage to the lungs from should be vaccinated to prevent pneumococcal inhalation of a poisonous gas, such as chlorine, or by pneumonia. aspiration of foreign matter. The pneumonia can Antibiotic therapy for URIs determined to be range from a mild complication of URI to a life- caused by bacteria, such as streptococcus or staphylo- threatening illness. Bacterial pneumonia can be coccus, can prevent pneumonia. Prophylactic mea- community acquired by patients living independently sures against aspiration in stroke patients or those in in the community, or it may arise in a hospital an altered state of consciousness are prudent. setting associated with health care or with use of a ventilator. Patient Teaching Instruct the patient to take the full course of antibiot- Diagnosis ics and other medications as prescribed. Stress the The diagnostic evaluation begins with a physical importance of rest, plenty of fluid intake, and cough- examination, the patient history, and chest radio- ing to clear secretions. Counsel the patient to avoid graphic films to evaluate the pulmonary system. smoking, limit alcohol intake, and not to take over- Further tests, such as arterial blood gases, bronchos- the-counter medications. Tell the patient to seek copy, and sputum and blood cultures, are also prompt medical care for signs of respiratory infection done. in the future, to stay away from persons with infections, and to take seasonal influenza vaccine, if Treatment appropriate. Stress the importance of follow-up Treatment is based on the underlying cause of the appointments to determine sufficient resolution of pneumonia. Organism-specific antibiotics are pre- pneumonia.  CHAPTER 9 Diseases and Conditions of the Respiratory System 465 ALERT! Health Hazards of Common Molds wheezing. Severe reactions may occur among Recent concern about the health hazards of mold workers exposed to large amounts of molds in infestation in homes and other buildings has made its occupational settings. way into the public health media and medical arena. Those individuals who have decreased immunity, There are reports that toxic mold inside homes can such as those with acquired immunodeficiency cause allergic symptoms or unique or rare health syndrome (AIDS), or those with underlying lung conditions, such as pulmonary hemorrhage or memory disease or chronic diseases, are more susceptible loss. Reported cases of illnesses from molds, in the to fungal infections and allergic pneumonitis. indoor and outdoor environment, that contain A common sense approach that includes routine mycotoxins (poisons produced by fungi) have measures of control should be used for any mold prompted a plethora of questions from the public contamination existing inside homes and buildings. about how to determine mold infestation, what action Decisions about treatment required for extensive to take, and when to seek medical attention. Listed mold infestations of homes or buildings are made below are some facts presented to the public by the individually; sometimes professional cleaning Centers for Disease Control and Prevention (CDC): companies and reconstruction are employed. Molds grow naturally in both the indoor and In most cases, mold can be removed by a outdoor environments, especially where there is thorough cleaning with commercial products, soap