LRT Disorders Management PDF

11/17/2024 Lower Respiratory Tract Disorders Unit IV Chapter 23 Management of Patients With Chest and Lower Respiratory Tr...

11/17/2024 Lower Respiratory Tract Disorders Unit IV Chapter 23 Management of Patients With Chest and Lower Respiratory Tract Disorders Mrs. Asha Russel Asst. Science Tutor ‘A’ Learning Objectives Compare the lower pulmonary infections with regard to its causes, clinical manifestations, assessment findings, medical, surgical, nursing management, complications, and prevention. Formulate nursing care plan within the nursing process framework for care of patient with lower respiratory tract infection. 1  11/17/2024 Anatomic Overview of the Respiratory System The Upper Respiratory Tract: Nose; paranasal sinuses; pharynx, tonsils, and adenoids; larynx; and trachea. Infections are fairly common. Usually nothing more than an irritation The Lower Respiratory Tract: Lungs which contain the bronchial and alveolar structures needed for gas exchange. Infections are more dangerous. Can be very difficult to treat Function of the Respiratory System  Respiration  Ventilation  Oxygen Transport  Pulmonary Diffusion & Perfusion  Ventilation and Perfusion Balance & Imbalance  Gas Exchange 2  11/17/2024 Lower Respiratory Tract Disorders Atelectasis Pneumonia Pulmonary Tuberculosis Atelectasis Atelectasis may occur in adults as a result of reduced ventilation (non-obstructive atelectasis) or any blockage that obstructs passage of air to and from the alveoli (obstructive atelectasis), thus reducing alveolar ventilation. Obstructive atelectasis is the most common type and results from reabsorption of gas (trapped alveolar air is absorbed into the bloodstream); no additional air can enter into the alveoli because of the blockage. As a result, the affected portion of the lung becomes airless and the alveoli collapse. 3  11/17/2024 Atelectasis - Causes Causes of atelectasis include: 1.Foreign body 8.Increased abdominal pressure 2.Tumor or growth in an airway 9.Reduced lung volumes due to 3.Altered breathing patterns musculoskeletal or neurologic disorders 4.Retained secretions 10.Restrictive defects and 5.Pain 11.Specific surgical procedures (e.g., Upper 6.Alterations in small airway function abdominal, thoracic, or open heart surgery) 7.Prolonged supine positioning Atelectasis – Clinical Manifestations Signs and symptoms are insidious & include: Increasing dyspnea Cough and Sputum production. 4  11/17/2024 Atelectasis – Clinical Manifestations Acute Chronic Atelectasis involving large amount of Same signs & symptoms lung tissue (lobar atelectasis), marked Infection distal to the respiratory distress may be observed obstruction Tachycardia Signs and symptoms of a pulmonary Tachypnea infection also may be present Pleural pain and Central cyanosis (a bluish skin hue that is a late sign of hypoxemia) Difficulty breathing in the supine position and are anxious. Assessment and Diagnostic Findings Increased work of breathing and hypoxemia. Decreased breath sounds and crackles. A chest x-ray may suggest a diagnosis of atelectasis before clinical symptoms appear; the x- ray may reveal patchy infiltrates or consolidated areas. SPO2 is(lessthan 90%) or a low pressure of arterial oxygen (PaO2). Quality and Safety Nursing Alert: Tachypnea, dyspnea and mild-to-moderate hypoxemia are hallmarks of the severity of atelectasis. 5  11/17/2024 Atelectasis –Management  The goal of the treatment is to improve ventilation and remove secretions.  Strategies to prevent atelectasis include: Frequent turning Early ambulation Lung volume expansion maneuvers (e.g., deep-breathing exercises and incentive spirometry) and Coughing.  These measures serve as the first-line measures to minimize or treat atelectasis by improving ventilation. If patient doesn’t respond to first-line measures or who cannot perform deep- breathing exercises, What are other treatment modalities? PEEP: Positive End Expiratory Pressure (a simple mask and one-way valve system that provides varying amounts of expiratory resistance, usually 10 to 15cm H2O) CPAP: Continuous Positive Airway Pressure Bronchoscopy Chest physiotherapy Nebulizer treatments with a bronchodilator Thoracentesis if the cause is pleural effusion 6  11/17/2024 Atelectasis – Prevention Atelectasis – Prevention Multidisciplinary, evidence-based standardized intervention programs, such as ICOUGHSM (see Chart 23-2), hold promise in preventing atelectasis. 7  11/17/2024 Atelectasis – Complications Hypoxemia Acute Respiratory Failure Pneumonia Is an inflammation of the lung parenchyma caused by various microorganisms, including bacteria, mycobacteria, fungi and viruses. Pneumonitis is a more general term that describes an inflammatory process in the lung tissue that may place the patient at risk for microbial invasion. Pneumonia and influenza are the most common causes of death from infectious diseases in the United States. 8  11/17/2024 Pneumonia - Classification Classified as: Community-Acquired Health Care–Associated Hospital-Acquired Ventilator-Associated (HCAP) Types of pneumonia Description Etiology Community Organism (bacterial or Acquired Pneumonia occurring in the community or ≤48 hours after hospital virus) found in the Pneumonia (CAP) admission or institutionalization of patients who do not meet the community. Most common criteria for health care–associated pneumonia (HCAP) (S. pneumonia and influenza virus). Read other causes from TABLE 23-1, page : 1651 Health Pneumonia occurring in a nonhospitalized patient with extensive health Care care contact with one or more of the following: The causative Associated Hospitalization for ≥2 days in an acute care facility within pathogens are often Pneumonia 90 days of infection. MDR (Multidrug (Nosocomial/ Residence in a nursing home or long-term care facility. resistant) HCAP) Antibiotic therapy, chemotherapy, or wound care within 30 days of current infection. Home infusion therapy or home wound care. Family member with infection due to multidrug-resistant bacteria. Hospital Enterobacter species, Acquired Pneumonia occurring ≥48 hours after hospital admission that did Escherichia coli, H. Pneumonia not appear to be incubating at the time of admission. influenzae, Klebsiella species, (HAP) Proteus, Serratia marcescens, Pseudomonas aeruginosa, methicillin- sensitive or methicillin- resistant Staphylococcus aureus (MRSA), and S. pneumoniae Ventilator Associated A type of HAP that develops ≥48 hours after endotracheal tube It is subtype of HAP Pneumonia (VAP) intubation. 9  11/17/2024 Pneumonia in the Aspiration Pneumonia Immunocompromised Host Pneumocystis pneumonia (PCP), The pulmonary consequences resulting from fungal pneumonias, and entry of endogenous or exogenous bacterias into Mycobacterium tuberculosis. the lower airway. Common pathogens : anaerobes, S.aureus, The organism that causes PCP is now Streptococcus species, and gram-negative known as Pneumocystis jiroveci instead of bacilli. Pneumocystis carinii. Substances other than bacteria may be aspirated into the lung, such as gastric contents, exogenous chemical contents, or irritating gases. Pneumonia – Risk Factors Table 23-2, Pg. No: 1659 describes risk factors for pneumonia; additional risk factors are travel or exposure to certain environments and residence in a long-term care facility. 10  11/17/2024 Pneumonia - Clinical Manifestations  Pneumonia varies in its signs and symptoms depending on the type, causative organism, and presence of underlying disease. Looks severely ill Sudden onset of chills, rapidly rising fever (38.5- 40°C) Pleuritic chest pain- aggravated by deep breathing & coughing Tachypnea (25 - 45breaths/minute) Respiratory distress (SOB, use of accessory muscles) Relative Bradycardia (a pulse–temperature deficit in which the pulse is slower than that expected for a given temperature) Might exhibit signs of upper respiratory chest infection such as headache, low grade fever, pleuritic pain, myalgia, rash and pharyngitis Pneumonia - Clinical Manifestations Mucoid or Mucopurulent sputum is expectorated Cheeks are flushed and lips and nail beds demonstrate central cyanosis Orthopnea Poor appetite Diaphoretic and tires easily Rusty, blood-tinged sputum may be expectorated with streptococcal (pneumococcal), staphylococcal, and Klebsiella pneumonia Presence of crackles Physical findings that indicate consolidation of lung tissue, including increased tactile fremitus (vocal vibration detected on palpation), percussion dullness, bronchial breath sounds, egophony (when auscultated, the spoken “E” becomes a loud, nasal-sounding “A”), and whispered pectoriloquy (whispered sounds are easily auscultated through the chest wall). 11  11/17/2024 Assessment and Diagnostic Findings  History (particularly of a recent respiratory tract infection),  Physical examination  Chest x-ray,  Blood culture (bloodstream invasion [bacteremia] occurs frequently)  Sputum examination (1) rinse the mouth with water to minimize contamination by normal oral flora (2) breathe deeply several times (3) cough deeply and (4) expectorate the raised sputum into a sterile container.  Bronchoscopy Pneumonia - Medical Management Pharmacological therapy (antibiotic) Switch from IV to oral (once hemodynamically stable) No MDR – Monotherapy with Ceftriaxone, Levofloxacin or Ertapenem MDR - Three drug therapy combination used; cephalosporin( ceftazidime), carbapenem (piperacillin/ tazobactam) and fluoroquinolone (vancomycin) Hydration Antipyretics Antitussive medications 12  11/17/2024 Pneumonia - Medical Management Warm, moist inhalations Antihistamine Bedrest Oxygen therapy- if hypoxemia is present Aggressive respiratory support measures: administration of high concentrations of oxygen (fraction of inspired oxygen [FiO2]), endotracheal intubation and mechanical ventilation. Table 23-3, Pg. No: 1663-1666 for the treatment of patients with pneumonia due to specific pathogens Pneumonia - Prevention Pneumococcal vaccination:  Pneumococcal conjugate vaccine (PCV13)  Pneumococcal polysaccharide vaccine (PPSV23) TABLE 23-2, Pg. No: 1659 Risk Factors and Preventive Measures for Pneumonia 13  11/17/2024 Pneumonia - Complications  Hypotension  Septic shock  Pleural effusion  Respiratory failure Pneumonia – Nursing Process  Assessment  The nurse monitors the patient for the following:  Vital signs  Secretions: Amount, Odor, Color  Cough: frequency and severity  Degree of tachypnea, shortness of breath  Changes in physical assessment findings (primarily assessed by inspecting and auscultating the chest)  Changes in the chest x-ray findings  In addition, assess older adult patients for unusual behavior, altered mental status, fatigue, edema, dehydration & concomitant heart failure. 14  11/17/2024 Pneumonia – Nursing Process (Diagnosis)  Nursing Diagnosis  Ineffective Airway Clearance  Fatigue and Activity Intolerance  Risk for Fluid Volume Deficit  Imbalanced Nutrition  Knowledge Deficit Pneumonia – Nursing Process  Nursing Interventions  Improving airway patency  Promoting rest and conserving energy  Promoting fluid intake  Maintaining adequate nutrition  Promoting patient knowledge  Monitoring and managing potential complications 15  11/17/2024 Pulmonary Tuberculosis Tuberculosis (TB) An infectious disease that primarily affects the lung parenchyma. The primary infectious agent, M. tuberculosis is an acid-fast aerobic rod that grows slowly and is sensitive to heat and ultraviolet light. Mycobacterium bovis and Mycobacterium avium have rarely been associated with the development of a TB infection. TB spreads from person to person by airborne transmission. An infected person releases droplet nuclei (usually particles 1to 5 mcm in diameter) through: talking, coughing, sneezing, laughing or singing. 16  11/17/2024 Pg. No: 1680 Pulmonary TB - Clinical Manifestations 17  11/17/2024 Pulmonary TB - Assessment and Diagnostic Findings Positive skin test ( tuberculin skin test/ mantoux test) Pulmonary TB - Assessment and Diagnostic Findings Positive Blood Test Positive Sputum Culture (acid-fast bacilli) Complete history Physical examination Chest x-ray Drug susceptibility testing - determines which drugs can kill the tubercle bacilli. 18  11/17/2024 Pulmonary TB – Medical Management Pulmonary TB is treated primarily with anti-TB agents for 6 to 12 months. A prolonged treatment duration is necessary to ensure eradication of the organisms and to prevent relapse. Several types of drug resistance must be considered when planning effective therapy: 1. Primary drug resistance: Resistance to one of the first-line anti-TB agents in people who have not had previous treatment 2. Secondary or acquired drug resistance: Resistance to one or more anti-TB agents in patients undergoing therapy 3. Multidrug resistance: Resistance to two agents, isoniazid (INH) and rifampin. The populations at greatest risk for multidrug resistance are those who are HIV positive, institutionalized, or homeless. Pulmonary TB – Medical Management In current TB therapy, four first-line medications are used: INH, rifampin (Rifadin), pyrazinamide (PZA), and ethambutol (Myambutol) (Table 23-4, Pg. No: 1687-1688). Combination medications, such as INH and rifampin (Rifamate) or INH, pyrazinamide, and rifampin (Rifater) and medications given twice a week (e.g., rifapentine [Priftin]) are available to help improve patient adherence. However, these medications are more costly. Combination Medications INH+ Rifampin INH +Pyrazinamide + Rifampin 19  11/17/2024 Pulmonary TB – Medical Management Multidrug-resistant TB is difficult to treat. Treatment is guided by sputum specimen culture and sensitivity testing as the patient typically is resistant to INH and/or rifampin. Usually three to five drugs are identified as appropriate to prescribe. Examples of these second-line drugs include: aminoglycosides, fluoroquinolones, capreomycin (Capastat), ethionamide (Trecator), para-aminosalicylate sodium, and cycloserine (Seromycin). Pulmonary TB – Medical Management Recommended treatment guidelines for newly diagnosed cases of pulmonary TB have two phases: an initial treatment phase and a continuation phase. The initial phase consists of a multiple-medication regimen of INH, rifampin, pyrazinamide, and ethambutol plus vitamin B6 50 mg. All are taken once a day and are oral medications. This initial intensive-treatment regimen is given daily for 8 weeks, after which options for the continuation phase of treatment include INH and rifampin or INH and rifapentine. The continuation regimen lasts for an additional 4 or 7 months. The 4-month period is used for the large majority of patients. People are considered noninfectious after 2 to 3 weeks of continuous medication therapy. 20  11/17/2024 Pulmonary TB – Medical Management INH also may be used as a prophylactic (preventive) measure for people who are at risk for significant disease. Prophylactic INH treatment involves taking daily doses for 6 to 12 months. Liver enzymes, blood urea nitrogen (BUN), and creatinine levels are monitored monthly. Sputum culture results are monitored for AFB to evaluate the effectiveness of treatment and the patient’s adherence to the treatment regimen. Pulmonary TB – Nursing Management Promoting Airway Clearance Promoting Adherence to Treatment Regimen Promoting Activity and Adequate Nutrition Preventing Transmission of Tuberculosis Infection Pg. No: 1689-1691 21  11/17/2024 Pleural Conditions Pleural conditions are disorders that involve the membranes covering the lungs (visceral pleura) and the surface of the chest wall (parietal pleura) or disorders affecting the pleural space. Pleural Conditions: Pleurisy Pleural Effusion Empyema 22  11/17/2024 Pleurisy Refers to the inflammation of both layers of the pleurae (parietal and visceral). Causes: Pleurisy may develop in conjunction with pneumonia or an upper respiratory tract infection, TB, or collagen disease; after trauma to the chest, pulmonary infarction, or PE; in patients with primary or metastatic cancer; and after thoracotomy. When the inflamed pleural membranes rub together during respiration (intensified on inspiration), the result is severe, sharp, knifelike pain. Pleurisy – Clinical Manifestations  The key characteristic of pleuritic pain is its relationship to respiratory movement.  Taking a deep breath, coughing, or sneezing worsens the pain.  Pleuritic pain is limited in distribution rather than diffuse; it usually occurs only on one side.  The pain may become minimal or absent when the breath is held.  It may be localized or radiate to the shoulder or abdomen.  Later, as pleural fluid develops, the pain decreases 23  11/17/2024 Pleurisy – Assessment & Diagnostic Findings In the early period, when little fluid has accumulated, a pleural friction rub can be heard with the stethoscope, only to disappear later as more fluid accumulates and separates the inflamed pleural surfaces. Diagnostic tests include:  Chest X-ray  Sputum analysis  Thoracentesis to obtain a specimen of pleural fluid for examination  Pleural biopsy (less common) Pleurisy – Medical Management  The objectives of treatment are to discover the underlying condition causing the pleurisy and to relieve the pain.  Prescribed analgesic agents and topical applications of heat or cold provide symptomatic relief.  A nonsteroidal anti-inflammatory drug may provide pain relief while allowing the patient to take deep breaths and cough more effectively.  If the pain is severe, an intercostal nerve block may be required 24  11/17/2024 Pleurisy – Nursing Management  Because the patient has pain on inspiration, the nurse offers suggestions to enhance comfort, such as turning frequently onto the affected side to splint the chest wall and reduce the stretching of the pleurae.  The nurse also educates the patient to use the hands or a pillow to splint the rib cage while coughing. Pleural Effusion A collection of fluid in the pleural space, is rarely a primary disease process; it is usually secondary to other diseases. Can be a complication of: heart failure, TB, pneumonia, pulmonary infections (particularly viral infections), nephrotic syndrome, connective tissue disease, PE and neoplastic tumors (bronchogenic carcinoma). 25  11/17/2024 Pleural Effusion - Clinical Manifestations  Clinical manifestations are caused by the underlying disease.  Pneumonia fever, chills, and pleuritic chest pain.  Malignant effusion dyspnea, difficulty lying flat, and coughing.  The severity of symptoms is determined by the:  Size of the effusion  Speed of its formation  Underlying disease Pleural Effusion - Assessment and Diagnostic Findings  Assessment of the area of the pleural effusion reveals:  Decreased or absent breath sounds  Decreased fremitus  Dull, flat sound on percussion  In case of a extremely large pleural effusion the assessment reveals a patient in acute respiratory distress.  Tracheal deviation away from the affected side may be apparent. 26  11/17/2024 Pleural Effusion - Assessment and Diagnostic Findings  Physical examination  Chest X-ray Confirm the presence of fluid  Thoracentesis In some instances, a lateral decubitus x-ray is obtained. For this x-ray, the patient lies on the affected side in a side-lying position. A pleural effusion can be diagnosed because this position allows for the “layering out” of the fluid, and an air–fluid line is visible.  Pleural fluid is analyzed by bacterial culture, Gram stain, AFB stain (for TB), red & white blood cell counts, chemistry studies (glucose, amylase, lactate dehydrogenase, and protein), cytologic analysis for malignant cells, and pH.  Pleural biopsy may be performed as a diagnostic tool. Pleural Effusion - Medical Management  Objectives of treatment to:  Discover the underlying cause  Prevent re-accumulation of fluid  Relieve discomfort, dyspnea, and respiratory compromise  Thoracentesis is performed:  To remove fluid  To obtain a specimen for analysis and  To relieve dyspnea and respiratory compromise 27  11/17/2024 Pleural Effusion - Medical Management  Pleural Effusions caused by malignancy:  Pleurodesis may be performed using either a thoracoscopic approach or a chest tube. (Pg. No: 1700) Pleural Effusion - Medical Management  Other treatments for pleural effusion caused by malignancy:  Surgical pleurectomy  Insertion of a small catheter attached to a drainage bottle for outpatient management (CareFusion) 28  11/17/2024 Pleural Effusion - Medical Management  Other treatments for pleural effusion caused by malignancy:  Implantation of a pleuroperitonial shunt Pleural Effusion - Nursing Management  Supporting the medical regimen  If a chest tube is inserted for talc instillation, pain management is a priority and the nurse helps the patient assume positions that are the least painful.  The nurse evaluates the patient’s pain level and administers analgesic agents as prescribed and as needed.  If the patient is to be managed as an outpatient with a pleural catheter for drainage, the nurse educates the patient and family about management and care of the catheter and drainage system. 29  11/17/2024 Empyema Is an accumulation of thick, purulent fluid within the pleural space, often with fibrin development and a loculated (walled-off) area where infection is located. Empyema - Clinical Manifestations Patient is acutely ill Signsandsymptoms are similar to those of an acute respiratory infection or pneumonia (Fever, night sweats, pleural pain, cough, dyspnea, anorexia, and weight loss). For immunocompromised patient the symptoms may be vague. 30  11/17/2024 Empyema - Assessment & Diagnostic Findings  Chest auscultation demonstrates decreased or absent breath sounds over the affected area, and there is dullness on chest percussion as well as decreased fremitus.  The diagnosis is established by chest CT.  Usually, a diagnostic thoracentesis is performed, often under ultrasound guidance. Empyema - Medical Management  The objectives of treatment are:  To drain the pleural cavity &  To achieve complete expansion of the lungs. The fluid is drained, and appropriate antibiotics (usually begun by the IV route) in large doses are prescribed based on the causative organism. Sterilization of the empyema cavity requires 4 to 6 weeks of antibiotics 31  11/17/2024 Empyema - Medical Management Drainage of pleural fluid depends on the stage of the disease and is accomplished by one of the following methods: 1. Needle aspiration (thoracentesis) 2. Tube thoracostomy (chest drainage using a large-diameter intercostal tube attached to water-seal drainage) 3. Open chest drainage via thoracotomy, including potential rib resection, to remove the thickened pleura, pus, and debris and to remove the underlying diseased pulmonary tissue. Empyema - Medical Management With long-standing inflammation, an exudate can form in the lungs, trapping it and interfere with its normal expansion. Exudate must be removed surgically (decortication). 32  11/17/2024 Empyema - Nursing Management  Help the patient to cope with the condition and instruct the patient in lung expanding breathing exercises to restore normal respiratory function.  Provide care specific to the method of drainage of the pleural fluid.  Discharge instructions:  Care of the drainage system and drain site  Measurement and observation of drainage  Signs and symptoms of infection  When to contact the primary provider Pulmonary Embolism 33  11/17/2024 Pulmonary Embolism Refers to the obstruction of the pulmonary artery or one of its branches by a thrombus (or thrombi) that originates somewhere in the venous system or in the right side of the heart. VTE is a term that includes both DVT and PE. Associated with trauma, surgery (orthopedic, major abdominal, pelvic, gynecologic), pregnancy, heart failure, age older than 50 years, hypercoagulation states, and prolonged immobility. Pulmonary Embolism - Clinical Manifestations  Symptoms of PE depend on the size of the thrombus and the area of the pulmonary artery occluded by the thrombus.  Dyspnea the most frequent symptom  Chest pain is common, sudden and pleuritic in origin  It may be substernal & may mimic angina pectoris or a myocardial infarction  The most frequent sign is tachypnea  Other symptoms include anxiety, fever, tachycardia, apprehension, cough, diaphoresis, hemoptysis and syncope. 34  11/17/2024 Pulmonary Embolism - Clinical Manifestations  The clinical picture may mimic that of bronchopneumonia or heart failure.  Obstruction of the pulmonary artery results in pronounced dyspnea, sudden substernal pain, rapid and weak pulse, shock, syncope, and sudden death. Pulmonary Embolism - Assessment & Diagnostic Findings  Death from acute PE commonly occurs within 1 hour after the onset of symptoms; therefore, early recognition and diagnosis are priorities.  Initially, a clinical assessment will focus on the clinical probability of risk, clinical history, symptoms, signs, and testing.  The initial diagnostic workup may include chest x-ray, ECG, pulse oximetry, ABG analysis and V/Q scan (A VQ scan looks at the air supply (ventilation) and blood supply (perfusion) to your lungs).  Multi-detector-row computed tomography angiography (MDCTA) is the criterion standard for diagnosing PE.  Pulmonary angiography is considered a reasonable alternative diagnostic method. 35  11/17/2024 Pulmonary Embolism - Prevention  General Preventive Measures  Active leg exercises to avoid venous stasis  Early ambulation  Use of anti-embolism stockings Pulmonary Embolism - Medical Management  Because PE is often a medical emergency, emergency management is of primary concern.  After emergency measures have been initiated and the patient is stabilized, the treatment goal is to (1) dissolve (lyse) the existing emboli and (2) prevent new ones from forming.  Treatment may include a variety of modalities:  General measures to improve respiratory and vascular status  Anticoagulation therapy  Thrombolytic therapy and  Surgical intervention. 36  11/17/2024 PE - Medical Management (Emergency Management)  The immediate objective is to stabilize the cardiopulmonary system.  Emergency management consists of the following actions:  Nasal oxygen  IV infusion lines  Vasopressor therapy  MDCTA (Multi-detector-row computed tomography angiograph)  ECG  Serum electrolytes, CBC, & coagulation studies  Indwelling catheter  Small doses of morphine or sedatives Pg. No: 1722 PE - Medical Management (General Management)  Measures are initiated to improve respiratory and vascular status.  Oxygen therapy to correct the hypoxemia, relieve the pulmonary vascular vasoconstriction, and reduce the PH.  Use of anti-embolic stockings or intermittent pneumatic leg compression devices reduces venous stasis.  Elevating the legs (above the level of the heart) also increases venous flow. 37  11/17/2024 PE - Pharmacologic Therapy (Anticoagulation Therapy)  In patients with suspected PE, immediate anticoagulation is indicated to prevent a reoccurrence or extension of the thrombus and may continue up to 10 days.  Long-term anticoagulation is also indicated from 10 days to 3 months following the PE and is critical in the prevention of recurrence of VTE.  In patients with proven PE and who are hemodynamically stable, the initial anticoagulant selected may include (1) a low molecular weight heparin (e.g., enoxaparin), (2) unfractionated heparin, or (3) one of the new oral anticoagulants (NOACs), such as a direct thrombin inhibitor (e.g., dabigatran) or (4) a Factor Xa inhibitor (e.g., fondaparinux, rivaroxaban, apixaban, or edoxaban). PE - Pharmacologic Therapy (Anticoagulation Therapy)  The NOACs are contraindicated in patients who may receive thrombolytic therapy because their safety and efficacy are unknown in hemodynamically significant PE.  Unfractionated heparin is preferred in patients who are hemodynamically unstable in anticipation of a potential need for thrombolysis or embolectomy.  Long-term treatment options include warfarin (Coumadin) and the NOACs.  Warfarin dosing requires regular blood draws for international normalized ratio (INR) monitoring and has a higher bleeding risk.  An antidote (Vitamin K) is available if the INR is high and there is a risk of bleeding. 38  11/17/2024 PE - Pharmacologic Therapy (Thrombolytic Therapy) Thrombolytic therapy is used in patients with an acute PE who have hypotension and do not have a contraindication or potential bleeding risk. Thrombolytic therapy with recombinant tissue plasminogen activator (Activase) or other thrombolytic agents like kabikinase (Streptase) are used in treating massive PE, particularly in patients who are severely compromised (e.g., those who are hypotensive and have significant hypoxemia despite oxygen supplementation). PE - Pharmacologic Therapy (Thrombolytic Therapy)  The risk of bleeding is significant.  Contraindications to thrombolytic therapy include:  A cerebrovascular disease (stroke) within the past 2 months  Other active intracranial processes  Active bleeding  Surgery within 10 days of the thrombotic event  Recent labor and delivery  Trauma or  Severe hypertension.  Consequently, thrombolytic agents are advocated only for PE affecting a significant area of blood flow to the lung and causing hemodynamic instability. 39  11/17/2024 PE - Pharmacologic Therapy (Thrombolytic Therapy)  Before thrombolytic therapy is started, INR, partial thromboplastin time (PTT), hematocrit, and platelet counts are obtained.  An anticoagulant is stopped prior to administration of a thrombolytic agent.  During therapy, all but essential invasive procedures are avoided because of potential bleeding.  If necessary, fresh whole blood, packed red cells, cryoprecipitate, or frozen plasma is given to replace blood loss and reverse the bleeding tendency.  After the thrombolytic infusion is completed (which varies in duration according to the agent used), maintenance anticoagulation therapy is initiated. PE - Pharmacologic Therapy (Thrombolytic Therapy)  Importance of Thrombolytic Therapy  Thrombolytic therapy resolves the thrombi or emboli quickly and restores more normal hemodynamic functioning of the pulmonary circulation, thereby reducing pulmonary hypertension & improving perfusion, oxygenation, and cardiac output. 40  11/17/2024 Pulmonary Embolism - Surgical Management  A surgical embolectomy is rarely performed but may be indicated if the patient has a massive PE or hemodynamic instability or if there are contraindications to thrombolytic (fibrinolytic) therapy. Pulmonary Embolism - Surgical Management  Embolectomy can be also performed using catheters. 41  11/17/2024 Pulmonary Embolism - Surgical Management  For patients who have an absolute contraindication to therapeutic anticoagulation or when recurrent PE occurs despite therapeutic anticoagulation, an inferior vena cava (IVC) filter may be inserted.  This filter provides a screen in the IVC, allowing blood to passthrough while large emboli from the pelvis or lower extremities are blocked or fragment before reaching the lung. Greenfield filter Pulmonary Embolism - Nursing Management  Minimizing the risk of pulmonary embolism  Preventing thrombus formation  Assessingpotential for pulmonary embolism  Monitoring thrombolytic (fibrinolytic) therapy  Managing pain  Managing oxygen therapy Pg. No: 1725 - 1729 42  11/17/2024 Pulmonary Embolism - Nursing Management  Relieving anxiety  Monitoring for complications  Providing post operative nursing care  Promoting home & community-based care  Patient education instructions Pg. No: 1725 - 1729 43