NCM112 Medical-Surgical Nursing Midterms PDF

NCM112: Medical-Surgical Nursing Prof.: Jayson Yap | Midterms throat, general malaise, chills, and often headache and muscle aches. may last 1-2 wks.. Topic Outline:...

NCM112: Medical-Surgical Nursing Prof.: Jayson Yap | Midterms throat, general malaise, chills, and often headache and muscle aches. may last 1-2 wks.. Topic Outline: Management of Patients with Upper Respiratory symptomatic therapy that includes an adequate Diseases fluid intake, rest, prevention of chilling, and use Management of Patients with Chest and Lower of expectorants as needed, warm salt-water Respiratory Diseases gargles, nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen, relieve MANAGEMENT OF PATIENTS WITH UPPER AIRWAY aches and pains. DISEASES Antihistamines are used to relieve sneezing, UPPER AIRWAY INFECTIONS rhinorrhea, and nasal congestion, Guaifenesin to RHINITIS promote removal of secretions, amantadine and rimantadine, topical therapy delivers medication group of disorders characterized by directly to the nasal mucosa. inflammation and irritation of the mucous membranes of the nose. RHINOSINUSITIS (ACUTE) Allergic rhinitis is further classified as seasonal or perennial rhinitis, occurs during pollen classified as acute bacterial rhinosinusitis seasons, and perennial rhinitis occurs (ABRS) or viral rhinosinusitis (AVRS). throughout the year. S/S: Nasal congestion, caused by inflammation, Seasonal rhinitis occurs during pollen seasons, edema, and transudation of fluid secondary to and perennial rhinitis occurs throughout the URI, leads to obstruction of the sinus cavities. year. Bacterial organisms account for more than 60% signs and symptoms of rhinitis include of the cases of acute sinusitis. Typical rhinorrhea, nasal congestion; nasal discharge, pathogens include Str. pneumoniae, sneezing and pruritus of the nose, roof of the Haemophilus influenzae, and less commonly mouth, throat, eyes, and ears. Stp. aureus and Moraxella catarrhalis. Management: if viral rhinitis is the cause, Tenderness to palpation over the infected sinus medications may be prescribed to relieve the area. Flexible endoscopic culture techniques symptoms. In allergic rhinitis, allergy tests may and swabbing of the sinuses. be performed to identify possible allergens. complications include osteomyelitis and Pharmacologic: Antihistamines remain the most mucocele (cyst of the paranasal sinuses). common treatment, oral decongestant agents Oral therapies can include antibiotics - bacterial may be used for nasal obstruction, saline nasal cases, oral corticosteroids - acute inflammation, spray can act as a mild decongestant, intranasal Amoxicillin, levofloxacin (penicillin allergy), corticosteroids, ophthalmic agents (cromolyn cephalosporins such as cephalexin (Keflex), ophthalmic solution 4%). cefuroxime (Ceftin), cefaclor (Ceclor), and instruct the patient on the correct administration cefixime (Suprax), saline lavage and of nasal medications (blow nose, keep head decongestants (guaifenesin/pseudoephedrine), upright, spray away from nasal septum, wait 1 OTC antihistamines like diphenhydramine. minute before second spray, never share with explain to the patient that fever, severe other people). headache, and nuchal rigidity are signs of potential complications. VIRAL RHINITIS/COMMON COLD CHRONIC RHINOSINUSITIS AND infectious, acute inflammation of the mucous RECURRENT ACUTE RHINOSINUSITIS membranes of the nasal cavity. S/S: low-grade fever, nasal congestion, Mechanical obstruction of the sinus drainage rhinorrhea and nasal discharge, halitosis, (ostiomeatal complex) leads to chronic sneezing, tearing watery eyes, “scratchy” or sore Drey | 1  inflammation, impaired ciliary function, and buildup of mucus in the sinuses. TONSILLITIS AND ADENOIDITIS Infections (bacterial or viral) and environmental factors (allergens, pollutants) may contribute to ongoing inflammation. Infection of the tonsils and adenoids, typically Manifestations: Nasal congestion, facial caused by bacteria (e.g., Streptococcus) or pain/pressure, thick nasal discharge, decreased viruses. sense of smell, postnasal drip. Inflammation can block the airway, leading to Diagnostics: Physical examination of nasal breathing difficulties, especially in children. cavities, Imaging: CT scan of the sinuses to Manifestations: Sore throat, fever, snoring, assess mucosal thickening, polyps, and difficulty swallowing, ear pain (adenoiditis). obstruction, Nasal endoscopy for visual Diagnostics: RSAT is quick and convenient; assessment of sinus drainage. however, it is less sensitive than the throat swab Management: Medications: Intranasal culture. The tonsillar site is cultured to determine corticosteroids, antibiotics for bacterial the presence of bacterial infection. infections, saline nasal irrigation, Surgical: Management: Medical: Antibiotics for bacterial Functional endoscopic sinus surgery (FESS) for infection, supportive care with analgesics and severe or refractory cases to restore sinus hydration, Surgical: Tonsillectomy or drainage, Allergy Management: Immunotherapy adenoidectomy for recurrent infections or airway for patients with allergic rhinitis. obstruction. ACUTE PHARYNGITIS PERITONSILLAR ABSCESS Viral or bacterial infection of the pharynx, leading to inflammation. Group A Streptococcus is the most common Collection of pus between the tonsillar capsule bacterial cause (Strep throat). and surrounding tissues, often a complication of Manifestations: Sore throat, difficulty swallowing, untreated or severe tonsillitis. fever, swollen tonsils, exudates, absence of most common major suppurative complication of cough in bacterial cases. sore throat. The collection of purulent exudate Diagnostics: Throat swab for rapid antigen between the tonsillar capsule and the detection test (RSAT) or throat culture, Physical surrounding tissues, including the soft palate. exam: swollen tonsils, erythema, exudates. The most common causative organism is Management: Viral: Symptomatic treatment GABHS (group A beta-hemolytic streptococci). (analgesics, warm salt-water gargles), Bacterial Manifestation: Severe sore throat, fever, difficulty (Streptococcal): Antibiotics (penicillin or opening mouth (trismus), drooling, muffled voice. amoxicillin), supportive care with analgesics and Diagnostics: Intraoral ultrasound and hydration. transcutaneous cervical ultrasound Drainage of the abscess via needle aspiration or CHRONIC PHARYNGITIS incision, Antibiotic therapy (penicillin or clindamycin), Tonsillectomy if abscess recurs. Persistent irritation of the pharynx due to LARYNGITIS environmental factors (smoking, dust), chronic infections, or vocal strain. Manifestations: Constant throat irritation, dry Inflammation of the larynx, commonly due to cough, hoarseness, mucus in the throat. voice strain, infections (viral), or exposure to Management: Eliminate irritants (e.g., smoking irritants. cessation), Symptomatic relief with throat Manifestations: Hoarseness, loss of voice, dry lozenges, saline gargles, Treat underlying cough, throat irritation. conditions like chronic GERD if present. Drey | 2  Diagnostics: Laryngoscopy to visualize vocal Obstruction of airflow through the nasal cord inflammation, Throat cultures to rule out passages caused by conditions such as: bacterial infection. Deviated nasal septum: Displacement of the Management: Voice rest, hydration, steam nasal septum, often due to trauma. Nasal inhalation, Antibiotics if bacterial infection is polyps: Soft, painless growths on the lining of confirmed, For chronic cases, treatment of nasal passages. Hypertrophy of turbinates: underlying causes like GERD Enlargement of the bony structures inside the nose due to chronic inflammation or allergies. Manifestations: Difficulty breathing through the OBSTRUCTIVE SLEEP APNEA nose, snoring, recurrent sinus infections, mouth breathing. Diagnostic Workups: Physical examination of Recurrent episodes of upper airway collapse nasal passages, Nasal endoscopy to visualize during sleep, leading to intermittent hypoxia and internal structures, CT scan of sinuses in chronic sleep fragmentation. or severe cases. Manifestations: Loud snoring, episodes of Management: Medications: Nasal corticosteroids apnea, daytime sleepiness, fatigue, gasping for inflammation, antihistamines if allergies are during sleep. involved, decongestants for temporary relief. Diagnostics: Polysomnography (sleep study) to Surgery: Septoplasty for deviated septum, assess apnea-hypopnea index (AHI) and polypectomy for nasal polyps, turbinate oxygen saturation during sleep. reduction surgery if hypertrophy is severe, Management: Lifestyle Changes: Weight loss, Supportive Care: Saline nasal sprays, avoidance of alcohol and sedatives, Devices: humidification to relieve nasal dryness and CPAP (Continuous Positive Airway Pressure) or irritation. BiPAP, Surgical: Uvulopalatopharyngoplasty (UPPP) or mandibular advancement in severe FRACTURES OF THE NOSE cases. Fracture of the nasal bones, typically caused by direct trauma (e.g., physical assault, falls, sports EPISTAXIS injuries). Can involve displacement of nasal bones, septal hematoma, and potential airway obstruction. Rupture of small blood vessels in the nasal Manifestations: Nasal deformity, swelling, mucosa, often due to trauma, dryness, or bruising, difficulty breathing through the nose, underlying conditions like hypertension. nosebleeds. Manifestations: Sudden onset of nosebleed, Diagnostic Workups: Physical examination to which may be mild or heavy. assess external deformities, swelling, and Diagnostics: Visual inspection to locate the tenderness. X-ray or CT scan to determine the bleeding site and Nasal endoscopy in recurrent extent of the fracture and any displacement. cases. Inspection for septal hematoma, which can lead Management: Direct pressure on the nostrils, to long-term complications if untreated. cauterization (silver nitrate) for visible bleeding, Management: Initial Treatment: Apply cold Nasal packing for persistent bleeding, Treat compresses, provide analgesia, and assess for underlying causes (e.g., hypertension control, other facial injuries, Reduction: Closed or open humidification for dry air). reduction to realign displaced nasal bones, typically done within 3-7 days after the injury (once swelling subsides), Surgical Intervention: NASAL OBSTRUCTION Septorhinoplasty or rhinoplasty may be necessary for severe deformities or functional obstruction of the passage of air through the impairments, Follow-up: Monitor for signs of nostrils. Drey | 3  infection or airway obstruction, especially if Cough suppressants, hydration, expectorants, septal hematoma is present. Bronchodilators for airway inflammation. LARYNGEAL OBSTRUCTION PNEUMONIA Swelling or blockage of the larynx, caused by Pneumonia is an inflammation of the lung foreign bodies, infections, or allergic reactions. parenchyma caused by microorganisms such as Can lead to life-threatening airway obstruction. bacteria, viruses, fungi, or mycobacteria​. Manifestations: Stridor, difficulty breathing, Manifestations: Fever, cough, pleuritic chest cyanosis, use of accessory muscles. pain, Tachypnea, purulent sputum, cyanosis (in Diagnostic workups: Direct laryngoscopy to severe cases), Fatigue, headache, myalgia. visualize obstruction, Imaging (X-ray or CT) for Pneumonia arises from aspirated flora from the foreign bodies. oropharynx or bloodborne organisms. This Management: Removal of foreign body via causes exudate formation, blockage of alveoli, Heimlich maneuver or laryngoscopy, and inflammation, impairing ventilation and gas Epinephrine and corticosteroids for allergic exchange​. reactions, emergency tracheotomy in severe Diagnostics: History of recent respiratory tract cases. infection, Physical Exam: Tachypnea, tachycardia, chest pain, Chest X-ray: Pulmonary MANAGEMENT OF PATIENTS WITH CHEST AND infiltrates, Sputum Culture and Blood Culture to LOWER AIRWAY DISEASES identify the pathogen, Bronchoscopy if LOWER AIRWAY INFECTIONS necessary. ATELECTASIS Management: Antibiotics tailored to the pathogen (e.g., macrolides or fluoroquinolones), Collapse of alveoli, leading to reduced gas Supportive Care: Oxygen therapy, hydration, exchange, often due to obstruction of airways, antipyretics​ pressure on the lung, or surfactant deficiency. Manifestations: Shortness of breath, diminished COMMUNITY-ACQUIRED PNEUMONIA breath sounds, cough, cyanosis in severe cases. Diagnostics: Chest X-ray to visualize collapsed CAP is an infection acquired outside of a lung areas, Pulse oximetry and arterial blood hospital or within 48 hours of hospitalization​. gasses to assess oxygenation. Manifestations: Sudden onset of fever, chills, Management: Prevention: Early mobilization, Pleuritic chest pain, cough with purulent sputum, deep breathing exercises, incentive spirometry, Tachypnea, dyspnea Treatment: Chest physiotherapy,bronchodilators, Often caused by Streptococcus pneumoniae, H. mechanical ventilation if necessary. influenzae, and sometimes atypical organisms like Mycoplasma pneumoniae​ ACUTE TRACHEOBRONCHITIS Diagnostics: Chest X-ray: Confirms infiltrates, Sputum Culture and Blood Culture for pathogen Inflammation of the trachea and bronchi, often identification​ following a viral or bacterial upper respiratory Management: Antibiotics: Macrolides (e.g., infection. azithromycin) for healthy outpatients; Manifestations: Cough (initially dry, then fluoroquinolones for those with comorbidities​, productive), fever, malaise, wheezing, shortness Hospitalization for severe cases with oxygen of breath. therapy and intravenous antibiotics​ Diagnostics: Sputum culture to identify bacterial pathogens. Chest X-ray if pneumonia is HOSPITAL-ACQUIRED PNEUMONIA suspected. Management: Antibiotics: For bacterial infections Pneumonia acquired after 48 hours of hospital (S. pneumoniae, H. influenzae), Symptomatic: admission in a patient with no prior symptoms of infection Drey | 4  Manifestations: New pulmonary infiltrates on Oxygen, positioning, possible mechanical chest X-ray, Fever, increased respiratory rate, ventilation and hypoxia, Purulent sputum production​. Often caused by multidrug-resistant organisms ASPIRATION like MRSA, Pseudomonas aeruginosa, or Klebsiella species​ Aspiration occurs when food, liquid, or other Diagnostics: Chest X-ray: New infiltrates, Blood material is inhaled into the lungs rather than and Sputum Cultures to identify the pathogen, swallowed into the esophagus, potentially Bronchoscopy in certain cases​ causing lung infections or pneumonitis. Management: Broad-spectrum antibiotics (e.g., Manifestations: Coughing or choking during ceftriaxone, levofloxacin), For multidrug-resistant eating or drinking, Shortness of breath or organisms, a combination of antibiotics, such as wheezing, Tachypnea, fever, and foul-smelling vancomycin for MRSA​. sputum in infection-related cases, Cyanosis and respiratory distress in severe cases. PNEUMONIA IN THE IMMUNOCOMPROMISED HOST Aspiration leads to an inflammatory response in the lungs as foreign material enters the Pneumonia in individuals with weakened tracheobronchial tree. immune systems, such as those on It can cause mechanical obstruction, chemical immunosuppressive drugs, chemotherapy, or pneumonitis (if acidic), or bacterial pneumonia with AIDS​ due to the introduction of oral flora. Manifestations: Similar to CAP: Sudden onset of Diagnostics: Chest X-ray: To identify infiltrates, fever, chills, Pleuritic chest pain, cough with especially in the right lung, Sputum cultures: To purulent sputum, Tachypnea, dyspnea, but may identify causative organisms in aspiration be more severe, Symptoms can include fever, pneumonia, Bronchoscopy: To remove foreign cough, dyspnea, and weight loss​ bodies and visualize damage. Common pathogens include Pneumocystis Management: Prevention: Position patients jiroveci (formerly P. carinii), fungi, upright during meals, especially those at high cytomegalovirus, and Mycobacterium risk, Medical: Antibiotics if pneumonia develops, tuberculosis. bronchodilators for airway obstruction, and Diagnostics: Sputum and Blood Cultures, Chest suctioning if necessary, Supportive Care: X-ray or CT Scan for infiltrates Bronchoscopy for Oxygen therapy, fluid replacement, and deeper sampling​ mechanical ventilation if necessary. Management: Antifungal or antiviral therapies (depending on pathogen), Supportive care SEVERE ACUTE RESPIRATORY SYNDROME including oxygen therapy and hydration​. A viral respiratory illness caused by the SARS ASPIRATION PNEUMONIA coronavirus (SARS-CoV), characterized by severe respiratory distress. Pneumonia caused by inhalation of foreign Manifestations: High fever (>100.4°F or material, such as food, liquids, or gastric 38°C),Dry cough, dyspnea, and hypoxia, contents, into the lungs​ Myalgia, headache, and diarrhea may be Manifestations: Cough, dyspnea, fever, present, progression to respiratory failure in Respiratory distress, cyanosis, and hypoxia​ severe cases. Aspiration can cause chemical injury to the SARS-CoV attacks the epithelial cells of the lungs (gastric acid), leading to inflammation, respiratory tract, leading to diffuse alveolar alveolar damage, and bacterial superinfection damage and the release of inflammatory Diagnostics: Chest X-ray to identify infiltrates, cytokines. Sputum Culture if secondary infection is This results in increased alveolar permeability, suspected​ pulmonary edema, and severe hypoxia. Management: Antibiotics to target anaerobic Diagnostics: PCR testing for the SARS virus, bacteria (e.g., clindamycin), Supportive care: Chest X-ray: Shows diffuse infiltrates similar to Drey | 5  ARDS, Blood tests: Leukopenia, Diagnosis: Chest X-ray or CT scan to detect thrombocytopenia, and elevated liver enzymes cavitation or abscess, Sputum culture to identify may be noted. causative organisms, Bronchoscopy may be Management: Isolation to prevent spread, used to rule out malignancy and drain Supportive care: Oxygen therapy, mechanical abscesses. ventilation in severe cases, Antivirals and Management: Antibiotics: Long-term use corticosteroids have been used, but efficacy is (clindamycin or metronidazole for anaerobes), uncertain, Monitoring: Continuous respiratory Drainage: Percutaneous drainage or surgical status monitoring, fluid management to avoid resection in severe cases, Supportive Care: overload. Oxygen therapy, hydration, nutritional support. PULMONARY TUBERCULOSIS PLEURISY A chronic infectious disease caused by Inflammation of the pleura, often secondary to Mycobacterium tuberculosis, primarily affecting lung infection, injury, or systemic disease. the lungs. Manifestations: Sharp, stabbing chest pain that Manifestations: Persistent cough (lasting 3 worsens with deep breathing, coughing, or weeks or longer), often with hemoptysis, Night movement, Pleural friction rub on auscultation, sweats, unexplained weight loss, fever, and Dyspnea and shallow breathing. fatigue, Chest pain and shortness of breath in Inflammation causes the pleural layers to rub advanced cases. together, leading to pain with movement. TB bacilli are inhaled and reach the alveoli, Pleural effusion may develop if the inflammation where they are phagocytized by macrophages. leads to fluid buildup. Granuloma formation occurs (Ghon complexes), Diagnostics: Chest X-ray or CT scan to detect containing the infection but also causing tissue pleural thickening or effusion, Pleural fluid necrosis in active disease. analysis (if effusion is present), Ultrasound for Diagnostics: Mantoux tuberculin skin test (TST) pleural effusion evaluation. or Interferon-Gamma Release Assays (IGRAs), Management: Pain Relief: NSAIDs are often Chest X-ray: Shows nodular lesions, cavitations, used to control pleuritic pain, Treat underlying or pleural effusion, Sputum cultures and cause: Antibiotics for infections, corticosteroids Acid-Fast Bacillus (AFB) smears for for autoimmune causes, Thoracentesis if fluid confirmation. accumulates. Management: Pharmacologic Therapy: A combination of drugs (isoniazid, rifampin, PLEURAL EFFUSION pyrazinamide, and ethambutol) over 6-9 months, Isolation: Airborne precautions during the active Accumulation of excess fluid in the pleural phase, Monitoring: Monthly sputum cultures, space. liver function tests due to drug toxicity. Manifestations: Dyspnea, chest pain, decreased breath sounds, and dullness on percussion, Dry LUNG ABSCESS cough and pleuritic pain. Fluid buildup may occur due to increased A localized collection of pus within the lung, capillary permeability (infections), decreased often secondary to aspiration, bacterial oncotic pressure (hypoalbuminemia), or pneumonia, or bronchial obstruction. impaired lymphatic drainage. Manifestations: Fever, productive cough with Diagnostics: Chest X-ray: Shows fluid foul-smelling, purulent sputum, Chest pain and accumulation, Thoracentesis: To analyze pleural weight loss, Hemoptysis in some cases. fluid for infection, malignancy, or Necrosis of lung tissue due to infection leads to transudate/exudate differentiation, Ultrasound or cavitation. CT scan: For guidance during thoracentesis. Surrounding lung tissue becomes inflamed, Management: Thoracentesis: To drain fluid and leading to a walled-off abscess filled with pus. relieve symptoms, Treat underlying cause: Drey | 6  Diuretics for heart failure, antibiotics for infections, Chest tube if there’s a large effusion. ACUTE RESPIRATORY FAILURE EMPYEMA A condition in which the respiratory system fails to maintain adequate gas exchange, resulting in Collection of pus in the pleural space, typically a hypoxemia or hypercapnia. complication of pneumonia, lung abscess, or Manifestations: Dyspnea, restlessness, thoracic surgery. confusion, and tachypnea, Cyanosis and use of Manifestations: Fever, chest pain, dyspnea, and accessory muscles for breathing, In hypercapnic productive cough, Signs of systemic infection failure: headache, bounding pulse, asterixis (e.g., chills, night sweats, weight loss). (flapping tremor). Infection in the pleural space causes pus to Caused by conditions that impair ventilation accumulate, leading to pleural thickening and (e.g., COPD exacerbation, pneumonia) or fibrosis if untreated. conditions that impair oxygenation (e.g., ARDS, Diagnostics: Chest X-ray or CT scan: To identify pulmonary embolism). fluid accumulation and loculations, Diagnostics: ABGs: Hypoxemia (PaO₂ < 60 mm Thoracentesis: For pleural fluid analysis, Pleural Hg) and/or hypercapnia (PaCO₂ > 45 mm Hg), biopsy if malignancy is suspected. Chest X-ray: To identify causes such as Management: Antibiotics: Long-term treatment pneumonia or pulmonary edema, Pulmonary based on culture results, Drainage: Chest tube function tests (PFTs): To assess lung function if insertion to remove pus, Decortication: Surgical chronic respiratory diseases are involved. removal of fibrous pleura if chronic empyema Management: Oxygen therapy: To correct develops. hypoxemia, Bronchodilators, corticosteroids, and antibiotics depending on the underlying cause, PULMONARY EDEMA Mechanical ventilation: In severe cases of ARF, Monitor ABGs, continuous pulse oximetry, and An abnormal accumulation of fluid in the alveoli treat underlying conditions. and interstitial spaces of the lungs, leading to impaired gas exchange. ACUTE RESPIRATORY DISTRESS SYNDROME Manifestations: Sudden onset of breathlessness, feeling of suffocation, Crackles on auscultation, A severe inflammatory response in the lungs, cyanosis, Pink, frothy sputum, Tachycardia, leading to non-cardiogenic pulmonary edema, anxiety, and confusion. decreased lung compliance, and severe Increased pressure in the pulmonary hypoxemia. vasculature (commonly due to left ventricular Manifestations: Rapid onset of severe dyspnea, failure) forces fluid from the capillaries into the tachypnea, Refractory hypoxemia (oxygen levels alveoli, causing impaired oxygen exchange and do not improve with supplemental oxygen), respiratory distress. Crackles, cyanosis, use of accessory muscles Diagnostics: Chest X-ray: Shows diffuse for breathing. infiltrates, typically in a "batwing" pattern, Arterial ARDS is characterized by increased blood gases (ABGs): Hypoxemia, hypercapnia in permeability of the alveolar-capillary membrane, severe cases, Echocardiogram: To evaluate causing fluid and proteins to leak into the alveoli, heart function if cardiogenic causes are leading to alveolar collapse and impaired gas suspected. exchange. Management: Oxygen therapy: To improve Diagnostics: Chest X-ray: Bilateral infiltrates oxygenation, Diuretics (e.g., furosemide): To (often described as "white-out"), ABGs: reduce fluid overload, Vasodilators (e.g., Persistent hypoxemia despite high oxygen nitroglycerin): To reduce preload and afterload, levels, Pulmonary artery catheterization: To Morphine: For anxiety and vasodilation, distinguish ARDS from cardiogenic pulmonary Mechanical ventilation if respiratory failure edema. occurs. Drey | 7  Management: Mechanical ventilation with low function tests (PFTs): To evaluate underlying tidal volumes and PEEP (positive end-expiratory lung disease, Chest X-ray: Shows right pressure) to keep alveoli open, Prone ventricular hypertrophy. positioning: To improve oxygenation, Fluid Management: Treat underlying lung disease management: Conservative fluid strategy to (e.g., bronchodilators for COPD), Oxygen avoid worsening pulmonary edema, Treat therapy: To relieve hypoxia and prevent further underlying causes (e.g., sepsis, trauma). pulmonary vasoconstriction, Diuretics: To manage fluid overload from right heart failure, PULMONARY ARTERIAL HYPERTENSION Vasodilators in severe cases of pulmonary hypertension. Increased blood pressure in the pulmonary arteries, leading to right ventricular overload and PULMONARY EMBOLISM failure. Manifestation: Dyspnea on exertion, chest pain, A blockage of a pulmonary artery or its branches fatigue, Syncope, especially during exertion, by a thrombus, fat, air, or tumor. Signs of right-sided heart failure (peripheral Manifestations: Sudden onset of dyspnea, chest edema, ascites). pain (pleuritic), tachypnea, tachycardia, PAH results from increased resistance in the Hemoptysis, syncope in large emboli, Anxiety, pulmonary arteries, often due to narrowing or hypotension, signs of right-sided heart strain. stiffening of the blood vessels. Over time, this A thrombus (most often originating from the increases pressure in the pulmonary circulation, deep veins of the legs—DVT) travels to the causing strain on the right side of the heart. pulmonary arteries, obstructing blood flow and Diagnostics: Echocardiogram: To assess right causing ventilation-perfusion mismatch, ventricular function and estimate pulmonary hypoxemia, and increased pulmonary pressures. artery pressures, Right heart catheterization: Diagnostics: CT pulmonary angiography (CTPA): The gold standard to measure pulmonary artery Gold standard for diagnosis, D-dimer: Elevated pressures, Pulmonary function tests (PFTs): To in the presence of a clot, Ventilation-perfusion assess for underlying lung disease. (V/Q) scan: If CT is contraindicated, ABGs: Management: Vasodilators (e.g., prostacyclin Hypoxemia, hypocapnia (due to analogs, endothelin receptor antagonists): To hyperventilation). reduce pulmonary pressures, Diuretics: To Management: Anticoagulation: Heparin followed manage fluid overload, Oxygen therapy for by oral anticoagulants (warfarin, NOACs), hypoxemia, Anticoagulation: To prevent Thrombolytic therapy for massive PE, Oxygen thromboembolic events, Lung transplantation in therapy and supportive care, Embolectomy or severe, refractory cases. vena cava filter placement in recurrent or life-threatening cases. PULMONARY HEART DISEASE (COR PULMONALE) SARCOIDOSIS Right ventricular enlargement and failure secondary to a lung disorder that causes Multisystem, granulomatous disease of unknown pulmonary hypertension. etiology. It may involve almost any organ or Manifestations: Dyspnea, fatigue, and chest tissue but most commonly involves the lungs, discomfort, Peripheral edema, jugular venous lymph nodes, liver, spleen, central nervous distension (JVD), Hepatomegaly and ascites. system, skin, eyes, fingers, and parotid glands. Chronic lung disease (e.g., COPD) leads to hypersensitivity response to one or more hypoxia and vasoconstriction in the pulmonary exogenous agents (bacteria, fungi, virus, arteries, causing increased pressure in the right chemicals) in people with an inherited or ventricle. This chronic strain eventually leads to acquired predisposition to the disorder. Results right-sided heart failure. in noncaseating granuloma formation due to the Diagnostic: Echocardiogram: To assess right release of cytokines and other substances that ventricular hypertrophy and function, Pulmonary promote replication of fibroblasts. Drey | 8  dyspnea, cough, hemoptysis, and congestion, results from sudden compression or positive anorexia, fatigue, and weight loss. pressure inflicted to the chest wall. Chest x-rays and CT are used to assess The most common causes of blunt chest trauma pulmonary adenopathy. A mediastinoscopy or are motor vehicle crashes (trauma from steering transbronchial biopsy may be used to confirm wheel, seat belt), falls, and bicycle crashes the diagnosis, confirmed by a biopsy that shows (trauma from handlebars). noncaseating granulomas. (1) Hypoxemia from disruption of the airway; Arterial blood gas measurements may be normal injury to the lung parenchyma, rib cage, and or may show hypoxemia and hypercapnia. respiratory musculature; massive hemorrhage; Corticosteroids may be beneficial because of collapsed lung; and pneumothorax their anti-inflammatory effects. Other cytotoxic (2) Hypovolemia from massive fluid loss from and immunosuppressive agents have been the great vessels, cardiac rupture, or used, but without the benefit of controlled clinical hemothorax trials. (3) Cardiac failure from cardiac tamponade, cardiac contusion, or increased intrathoracic OCCUPATIONAL LUNG pressure DISEASES/PNEUMOCONIOSIS assessment for airway obstruction, tension pneumothorax, open pneumothorax, massive Pneumoconiosis is caused by inhalation and hemothorax, flail chest, and cardiac tamponade. deposition of mineral dusts in the lungs, inspection of the airway, thorax, neck veins, and resulting in pulmonary fibrosis and parenchymal breathing difficulty. changes. In addition, the chest wall is assessed for Many people with early pneumoconiosis are bruising, petechiae, lacerations, and burns. The asymptomatic, but advanced disease often is vital signs and skin color are assessed for signs accompanied by disability and premature death. of shock.The thorax is palpated for tenderness Promote measures to reduce the exposure of and crepitus, and the position of the trachea is workers to industrial products (face masks, also assessed. hoods, industrial respirators). The initial diagnostic workup includes a chest Specific information that should be obtained x-ray, CT scan, complete blood count, clotting during assessment include the following: (1) studies, type and crossmatch, electrolytes, Exposure to an agent known to cause an oxygen saturation, arterial blood gas analysis, occupational disorder (2) Length of time from and ECG. exposure of agent to onset of symptoms (3) evaluate the patient’s condition and to initiate Congruence of symptoms with those of known aggressive resuscitation. exposure-related disorder (4) Lack of other more An airway is immediately established with likely explanations of the signs and symptoms oxygen support and, in some cases, intubation and ventilatory support. Reestablishing fluid volume and negative intrapleural pressure and draining intrapleural fluid and blood are essential. Strategies to restore and maintain cardiopulmonary function include ensuring an adequate airway and ventilation; stabilizing and reestablishing chest wall integrity; occluding any opening into the chest (open pneumothorax); and draining or removing any air or fluid from the thorax to relieve pneumothorax, hemothorax, or cardiac tamponade. Hypovolemia and low cardiac output must be corrected. CHEST BLUNT TRAUMA Drey | 9  FLAIL CHEST It is thought that injury to the lung parenchyma and its capillary network results in a leakage of occurs when three or more adjacent ribs serum protein and plasma. (multiple contiguous ribs) are fractured at two or The leaking serum protein exerts an osmotic more sites, resulting in free-floating rib pressure that enhances loss of fluid from the segments. capillaries. the chest wall loses stability, causing respiratory Blood, edema, and cellular debris (from cellular impairment and usually severe respiratory response to injury) enter the lung and distress. accumulate in the bronchioles and alveoli, where inspiration, the detached part of the rib segment they interfere with gas exchange. (flail segment) moves in a paradoxical manner An increase in pulmonary vascular resistance (pendelluft movement) in that it is pulled inward and pulmonary artery pressure occurs. The during inspiration. patient has hypoxemia and carbon dioxide On expiration, because the intrathoracic retention. pressure exceeds atmospheric pressure, the flail clinical manifestations vary from decreased segment bulges outward breath sounds, tachypnea, tachycardia, chest increased dead space, a reduction in alveolar pain, hypoxemia, and blood-tinged secretions to ventilation, and decreased compliance. Retained more severe tachypnea, tachycardia, crackles, airway secretions and atelectasis frequently frank bleeding, severe hypoxemia (cyanosis), accompany flail chest. and respiratory acidosis. The patient has hypoxemia, and if gas exchange efficiency of gas exchange is determined by is greatly compromised, respiratory acidosis pulse oximetry and arterial blood gas develops as a result of carbon dioxide retention. measurements. Pulse oximetry is also used. providing ventilatory support, clearing secretions The initial chest x-ray may show no changes; from the lungs, and controlling pain. changes may not appear for 1 or 2 days after If only a small segment of the chest is involved, the injury and appear as pulmonary infiltrates on the objectives are to clear the airway through chest x-ray. positioning, coughing, deep breathing, and MILD pulmonary contusion - adequate hydration suctioning to aid in the expansion of the lung, via IV fluids and oral intake, volume expansion and to relieve pain by intercostal nerve blocks, techniques, postural drainage, physiotherapy high thoracic epidural blocks, or cautious use of including coughing, and endotracheal suctioning IV opioids. are used to remove the secretions. For mild to moderate flail chest injuries, the Pain is managed by intercostal nerve blocks or underlying pulmonary contusion is treated by opioids via patient-controlled analgesia or by monitoring fluid intake and appropriate fluid other methods. Usually, antimicrobial therapy is replacement while relieving chest pain. administered. Pulmonary physiotherapy is performed. Supplemental oxygen is usually given by mask For severe flail chest injuries, endotracheal or cannula for 24 to 36 hours. intubation and mechanical ventilation are MODERATE - bronchoscopy may be required to required to provide internal pneumatic remove secretions. stabilization of the flail chest and to correct Intubation and mechanical ventilation with PEEP abnormalities in gas exchange. may also be necessary to maintain the pressure and keep the lungs inflated. PULMONARY CONTUSION Diuretics may be administered to reduce edema. A nasogastric tube is inserted to relieve Damage to the lung tissues resulting in gastrointestinal distention. hemorrhage and localized edema. It is a SEVERE - aggressive treatment with common thoracic injury and is frequently endotracheal intubation and ventilatory support, associated with flail chest. abnormal diuretics, and fluid restriction may be necessary. accumulation of fluid in the interstitial and Colloids and crystalloid solutions may be used to intra-alveolar spaces. treat hypovolemia. Drey | 10  typed and cross-matched in case blood STERNAL AND RIB FRACTURES transfusion is required. most common in motor vehicle crashes with a PNEUMOTHORAX direct blow to the sternum. Rib fractures - most common. occurs when the parietal or visceral pleura is Patients with sternal fractures have anterior breached and the pleural space is exposed to chest pain, overlying tenderness, ecchymosis, positive atmospheric pressure. crepitus, swelling, and possible chest wall Pain, minimal respiratory distress with slight deformity. chest discomfort, tachypnea with a small simple For patients with rib fractures, clinical or uncomplicated pneumothorax. manifestations are similar: severe pain, point If the pneumothorax is large and the lung tenderness, and muscle spasm over the area of collapses totally, acute respiratory distress the fracture that are aggravated by coughing, occurs. The patient is anxious, has dyspnea and deep breathing, and movement. air hunger, has increased use of the accessory A crackling, grating sound in the thorax muscles, and may develop central cyanosis from (subcutaneous crepitus) may be detected with severe hypoxemia. auscultation. The goal of treatment is to evacuate the air or The diagnostic workup may include a chest blood from the pleural space. x-ray, rib films of a specific area, ECG, A small chest tube (28 Fr) is inserted near the continuous pulse oximetry, and arterial blood second intercostal space; this space is used gas analysis. because it is the thinnest part of the chest wall, relieving pain, avoiding excessive activity, and minimizes the danger of contacting the thoracic treating any associated injuries. nerve, and leaves a less visible scar. If a patient Surgical fixation is rarely necessary unless also has a hemothorax, a large-diameter chest fragments are grossly displaced. tube (32 Fr or greater) is inserted, usually in the Sedation is used to relieve pain and to allow fourth or fifth intercostal space at the midaxillary deep breathing and coughing. Alternative line. strategies to relieve pain include an intercostal Once the chest tube or tubes are inserted and nerve block, ice over the fracture site or use of a suction is applied (usually to 20 mm Hg suction), chest binder. effective decompression of the pleural cavity Most rib fractures heal in 3 to 6 weeks. (drainage of blood or air) occurs. Autotransfusion may be needed. GUNSHOT AND STAB WOUNDS patient is instructed to inhale and strain against a closed glottis. most common causes of penetrating chest Antibiotics, the pleural cavity can be trauma. decompressed by needle aspiration Stab wounds are generally considered (thoracentesis) or by chest tube drainage of the low-velocity trauma because the weapon blood or air. destroys a small area around the wound. The chest wall is opened surgically Gunshot wounds may be classified as low, (thoracotomy) if more than 1500 mL of blood is medium, or high velocity. aspirated initially by thoracentesis or if chest restore and maintain cardiopulmonary tube output continues at greater than 200 mL/h. function. After an adequate airway is ensured and SIMPLE PNEUMOTHORAX ventilation is established, examination for shock and intrathoracic and intra-abdominal injuries is Occurs when air enters the pleural space necessary. through a breach of either the parietal or visceral diagnostic workup includes a chest x-ray, pleura. Most commonly, this occurs as air enters chemistry profile, arterial blood gas analysis, the pleural space through the rupture of a bleb pulse oximetry, and ECG. The patient’s blood is or a bronchopleural fistula. Drey | 11  When the lung or the air passages are injured, TRAUMATIC PNEUMOTHORAX air may enter the tissue planes and pass for Occurs when air escapes from a laceration in some distance under the skin (e.g., neck, chest). the lung itself and enters the pleural space or The tissues give a crackling sensation when from a wound in the chest wall. It may result palpated, and the subcutaneous air produces an from blunt trauma, penetrating chest or alarming appearance as the face, neck, body, abdominal trauma, or diaphragmatic tears. and scrotum become misshapen by Chest surgery can be classified as a traumatic subcutaneous air. pneumothorax, Open pneumothorax (sucking The subcutaneous air is spontaneously chest wounds) is one form of trauma. absorbed if the underlying air leak is treated or stops spontaneously. TENSION PNEUMOTHORAX In severe cases in which there is widespread subcutaneous emphysema, a tracheostomy is occurs when air is drawn into the pleural space indicated if airway patency is threatened by from a lacerated lung or through a small opening pressure of the trapped air on the trachea. or wound in the chest wall. a one-way valve or ball valve mechanism. With each breath, tension (positive pressure) is increased within the affected pleural space. This causes the lung to collapse and the heart, the great vessels, and the trachea to shift toward the unaffected side of the chest (mediastinal shift). The patient with a possible tension pneumothorax should immediately be given a high concentration of supplemental oxygen to treat the hypoxemia. CARDIAC TAMPONADE compression of the heart resulting from fluid or blood within the pericardial sac. It usually is caused by blunt or penetrating trauma to the chest. A penetrating wound of the heart is associated with a high mortality rate. Cardiac tamponade also may follow diagnostic cardiac catheterization, angiographic procedures, and pacemaker insertion, which can produce perforations of the heart and great vessels. Pericardial effusion with fluid compressing the heart also may develop from metastases to the pericardium from malignant tumors of the breast, lung, or mediastinum and may occur with lymphomas and leukemias, renal failure, TB, and high-dose radiation to the chest. SUBCUTANEOUS EMPHYSEMA Drey | 12