Altered Ventilatory Function - Module 07 PDF

ALTERED VENTILATORY FUNCTION COMPILER: GROUP 1 OVERVIEW TOPICS: Clients with ventilatory problems experience a. Acute and Chronic difficulties in breathing due to impaired function COPD of the lungs, respiratory muscles, or airways. b. Pulmonary These issues can range from acute conditions, Embolism such as respiratory failure, to chronic respiratory diseases like Chronic Obstructive Pulmonary c. Acute Respiratory Disease (COPD) or asthma. Managing these Distress Syndrome/ clients requires careful assessment and Acute Lung Injury interventions to ensure adequate oxygenation d. Respiratory Failure and ventilation. e. Pneumonia f. Respiratory Pandemics g. Pulmonary OUTLINE Hypertension h. Pneumothorax Students will encounter: a. Overview of the Disease b. Epidemiology c. Risk Factors d. Signs and Symptoms e. Types f. Detection and Diagnostic Evaluation g. Management and Treatment h. Prevention i. Prognosis j. Nursing Considerations ACUTE AND CHRONIC COPD I. OVERVIEW OF THE DISEASE COPD is a chronic, progressive lung disease characterized by persistent respiratory symptoms and airflow limitation, typically caused by significant exposure to noxious particles or gases. It encompasses two primary conditions: chronic bronchitis (inflammation and excess mucus in the airways) and emphysema (damage to the air sacs in the lungs), often occurring together. COPD leads to irreversible airflow obstruction, making it difficult for air to move in and out of the lungs. The disease progresses over time, causing significant morbidity and mortality worldwide. Acute COPD (Exacerbations) refers to sudden worsening of symptoms such as increased shortness of breath, cough, and sputum production, often triggered by infections or environmental pollutants. Chronic COPD involves long-term respiratory impairment, where airflow limitation is generally progressive and irreversible, leading to persistent symptoms of dyspnea (shortness of breath) and limited activity tolerance. II. EPIDEMIOLOGY COPD is the third leading cause of death worldwide, responsible for more than 3.23 million deaths annually, accounting for 6% of all deaths globally in 2019 (World Health Organization [WHO], 2022). The global prevalence of COPD in individuals aged 40 and above is estimated at 10.1%, though this varies by region (Global Burden of Disease Study [GBD], 2020). COPD caused approximately 74.4 million disability-adjusted life years making it a significant contributor to global health burden. The death rate varies across regions, with higher mortality rates reported in Southeast Asia, the Middle East, and parts of Africa, while high-income countries have seen declines in COPD-related deaths due to improved healthcare and smoking cessation efforts. National Epidemiology of COPD COPD affects approximately 15.7 million adults (6.4% of the adult population), according to the National Health Interview Survey (NHIS) (Centers for Disease Control and Prevention [CDC], 2022). However, due to underdiagnosis, the actual number may be closer to 24 million. The prevalence is higher in people aged 65 and older, as well as in women (7%) compared to men (5.4%) (CDC, 2022). III. RISK FACTORS Smoking – The leading cause of COPD. Long-term tobacco use damages the airways and alveoli. Environmental/Occupational Exposure – Long-term exposure to harmful pollutants, dust, chemicals, or secondhand smoke. Genetic Factors – Alpha-1 antitrypsin deficiency is a genetic condition that predisposes individuals to early-onset COPD. Age – Most people develop COPD later in life, typically over 40 years old. Respiratory Infections – Recurrent respiratory infections during childhood can increase the risk of developing COPD. IV. SIGNS AND SYMPTOMS Chronic obstructive pulmonary disease (COPD) is a progressive lung disease characterized by persistent airflow limitation. 1. Acute Exacerbation of COPD (AECOPD): An acute exacerbation is a sudden worsening of COPD symptoms, usually triggered by an infection, pollution, or other external factors: Increased shortness of breath: Patients may experience sudden and significant worsening of their baseline dyspnea, even at rest. Increased sputum production: There may be a sudden increase in the volume of mucus, often accompanied by a change in color (e.g., green or yellow), which may indicate infection. Worsening cough: The chronic cough may become more severe and frequent. Wheezing or noisy breathing: Exacerbations can cause increased airway inflammation and mucus, leading to louder or more frequent wheezing Chest pain or discomfort: This may worsen, particularly with coughing or deep breathing. Drowsiness: In severe exacerbations, patients may have difficulty thinking clearly due to low oxygen levels or high carbon dioxide levels (hypercapnia). Cyanosis: A bluish tint to the lips, fingers, or toes, indicating inadequate oxygenation. 2. Chronic COPD Symptoms: These symptoms develop over time and gradually worsen: Dyspnea (shortness of breath): One of the hallmark symptoms, often described as a feeling of breathlessness, especially during exertion, and it progressively worsens over time. Chronic cough: A persistent cough that is often productive, meaning it produces sputum (mucus), especially in the morning. Sputum production: Increased mucus production, which may be clear, white, yellow, or green in color, depending on the presence of infection. Wheezing: A whistling sound that occurs during breathing, commonly during exhalation, due to narrowed airways. Chest tightness: Some patients report discomfort or a feeling of tightness in the chest. Fatigue: Persistent tiredness and reduced ability to engage in physical activities due to poor oxygen exchange. Frequent respiratory infections: Due to impaired airway clearance mechanisms, patients are more prone to infections such as bronchitis or pneumonia. V. TYPES Chronic Bronchitis – Characterized by chronic productive cough for at least three months in two consecutive years, accompanied by mucus overproduction and airway inflammation. Emphysema – Destruction of the alveoli, leading to reduced lung surface area for gas exchange, causing breathlessness. Mixed COPD – A combination of both chronic bronchitis and emphysema. VI. DIAGNOSTIC AND DETECTION TEST 1. History and Physical Examination The detection of COPD begins with a thorough patient history and physical examination. Key elements include: History of smoking or environmental exposure: A detailed smoking history or exposure to environmental pollutants such as biomass fuel or occupational irritants is critical. Long-term exposure to these risk factors is closely associated with the development of COPD. Symptom assessment: Patients with COPD often present with a history of chronic cough, dyspnea (shortness of breath), and sputum production. These symptoms are persistent and progressive, particularly in chronic forms. Physical examination: Typical findings include decreased breath sounds, wheezing, prolonged expiratory phase, use of accessory muscles for breathing, and barrel chest. 2. Spirometry This lung function test involves the use of a machine called a spirometer. It measures the volume of air a person can forcefully exhale and is critical for confirming airflow limitation. 3. Chest Imaging (X-ray and CT scan) X-ray can help support the diagnosis of COPD by producing images of the lungs to evaluate symptoms of shortness of breath or chronic cough. CT images can identify emphysema better and at an earlier stage than a chest x-ray. 4. Arterial Blood Gas (ABG) ABG analysis is important for assessing oxygenation and carbon dioxide levels, especially during acute exacerbations of COPD (AECOPD). 5. Pulse Oximetry Pulse oximetry is a non-invasive tool used to assess oxygen saturation in patients with COPD. During acute exacerbations, oxygen saturation levels can drop significantly, and pulse oximetry helps monitor the need for supplemental oxygen. 6. Sputum Analysis and Microbiological Testing Sputum cultures can be helpful in identifying specific pathogens particularly in patients with frequent exacerbations or severe COPD. 7. Electrocardiogram (ECG) and Echocardiography These tests are used to assess the impact of COPD on the heart. Chronic COPD can lead to pulmonary hypertension and right heart failure. 8. Biomarkers and Laboratory Testing Complete blood count (CBC): A CBC may reveal elevated white blood cell count in acute exacerbations, suggesting infection or inflammation. Polycythemia may also be present in chronic COPD due to long-term hypoxemia. VII. MANAGEMENT AND TREATMENT The goal of COPD management is to reduce symptoms, slow disease progression, improve exercise tolerance, and prevent exacerbations. Bronchodilators: Short-acting (SABA) and long-acting (LABA) bronchodilators to open airways and relieve symptoms. Inhaled Corticosteroids (ICS): Reduce airway inflammation, especially in those with frequent exacerbations. Combination Therapy: LABA/ICS or LABA/LAMA (long-acting muscarinic antagonists) for more severe cases. Mucolytics: Help to thin mucus and facilitate expectoration. Antibiotics: Used during exacerbations caused by bacterial infections. Oxygen Therapy: For those with severe COPD and hypoxemia to maintain adequate oxygen levels. Pulmonary Rehabilitation: A comprehensive program that includes exercise training, nutritional advice, and education to improve quality of life. Vaccinations: Flu and pneumococcal vaccines to reduce infection risk. Non-Pharmacological Treatment Smoking Cessation: The most important intervention to slow disease progression. Physical Activity: Encouraged to improve respiratory muscle function. Surgery: Lung volume reduction surgery or, in extreme cases, lung transplantation for severe COPD. Management of Acute Exacerbations Short-acting bronchodilators: Administered more frequently. Systemic corticosteroids: Used to reduce inflammation during exacerbations. Antibiotics: If bacterial infection is suspected. Hospitalization: Severe exacerbations may require hospital management with supplemental oxygen or mechanical ventilation. Pharmacologic Treatment 1. Pharmacologic Treatment of Acute Exacerbations of COPD (AECOPD) a. Short-acting Bronchodilators Short-acting beta2-agonists (SABAs) and short-acting muscarinic antagonists (SAMAs) are the first-line treatment for AECOPD. Albuterol (SABA) Ipratropium (SAMA) are commonly used alone or in combination for immediate bronchodilation. These medications are often administered via nebulizer or metered-dose inhalers (MDIs) with spacers in acute settings. b. Systemic Corticosteroids Systemic corticosteroids are used to reduce inflammation and shorten the duration of an exacerbation. Oral or intravenous corticosteroids, such as Prednisone -are typically prescribed for 5-7 days. A typical regimen is 40 mg of prednisone daily for 5 days. This helps improve lung function and reduce the risk of treatment failure. c. Antibiotics Antibiotics are indicated during AECOPD when there is evidence of a bacterial infection, such as increased sputum purulence.Common prescribed antibiotics include: Amoxicillin-clavulanate Azithromycin Doxycycline 2. Pharmacologic Treatment for Chronic COPD a. Bronchodilators Bronchodilators are the foundation of COPD treatment. It helps to relax the smooth muscles in the airways and are used as maintenance therapy for COPD. Examples include: Salmeterol Formoterol Indacaterol b. Phosphodiesterase-4 (PDE4) Inhibitors Roflumilast is a PDE4 inhibitor used in patients with severe COPD associated with chronic bronchitis and frequent exacerbations. It reduces inflammation. c. Methylxanthines (Theophylline) Theophylline is a bronchodilator that is sometimes used in COPD management, though it is less preferred due to its narrow therapeutic index and the risk of side effects. It is generally reserved for patients who do not respond well to other treatments. VIII. PREVENTION Smoking Cessation: Quitting smoking is the most effective way to prevent the development of COPD and slow its progression. Avoid Environmental Irritants: Reduce exposure to harmful chemicals, dust, and air pollution. Vaccination: Annual influenza and pneumococcal vaccinations to prevent respiratory infections that may trigger COPD exacerbations. Early Diagnosis and Management of Respiratory Infections: Prompt treatment of upper respiratory infections can prevent exacerbations. IX. PROGNOSIS The general prognosis for chronic COPD is tied to the following factors: a. Disease Severity and Lung Function The severity of COPD is classified based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) staging. Mild COPD (GOLD 1): Patients with mild COPD often have a relatively stable disease course, particularly with appropriate management. These patients may live many years with minimal disability.Survival rate is 80%. Moderate to Severe COPD (GOLD 2 and 3): The prognosis worsens as the disease progresses, with patients experiencing more frequent symptoms and exacerbations.Survival rate is between 50% to 80%. Very Severe COPD (GOLD 4): Patients with very severe COPD have a significantly reduced life expectancy due to impaired lung function and frequent exacerbations.Survival rate is 30% to 50%. Prognosis of Acute Exacerbations of COPD (AECOPD) a. Short-term Mortality The short-term prognosis for AECOPD varies depending on the severity of the exacerbation and the need for hospitalization. Hospitalized patients face a significant risk of death, with mortality rates ranging from 5% to 11% during hospitalization. b. Long-term Impact The long-term prognosis following an AECOPD episode is also poor, particularly for patients who experience frequent exacerbations. These patients are at greater risk of future exacerbations, hospitalization, and death. A 1-year mortality rate following hospitalization for AECOPD can reach as high as 30%. X. NURSING CONSIDERATIONS 1. Regular monitoring of respiratory status, including breath sounds, oxygen saturation, and use of accessory muscles. 2. Evaluate the patient's history, including smoking, environmental exposures, and previous exacerbations. 3. Assess for symptoms of hypoxemia, hypercapnia (elevated CO2), and respiratory distress. 4. Teach patients about proper inhaler use and medication adherence. 5. Educate about the importance of smoking cessation and provide resources for support. 6. Encourage regular physical activity and participation in pulmonary rehabilitation. 7. Teach breathing techniques such as pursed-lip breathing to improve ventilation. 8. Administer oxygen as prescribed and monitor for signs of oxygen toxicity (especially in patients who are CO2 retainers). 9. Ensure proper equipment use and educate patients on home oxygen therapy. 10. Encourage small, frequent meals, as eating large meals may worsen dyspnea. 11. Work with a dietitian to manage nutritional needs, as COPD patients often have increased energy expenditure due to labored breathing. 12. Provide emotional support and screen for depression or anxiety, common in patients with chronic illness. 13. Encourage participation in support groups for patients with COPD. PULMONARY EMBOLISM I. OVERVIEW OF THE DISEASE A pulmonary embolism (PE) is a blood clot that develops in a blood vessel in the body (often in the leg). It then travels to a lung artery where it suddenly blocks blood flow. A blood clot that forms in a blood vessel in one area of the body, breaks off, and travels to another area of the body in the blood is called an embolus. An embolus can lodge itself in a blood vessel. This can block the blood supply to a particular organ. This blockage of a blood vessel by an embolus is called an embolism. The heart, arteries, capillaries, and veins make up the body's circulatory system. Blood is pumped with great force from the heart into the arteries. From there blood flows into the capillaries (tiny blood vessels in the tissues). Blood returns to the heart through the veins. As it moves through the veins back to the heart, blood flow slows. Sometimes this slower blood flow may lead to clot formation. II. EPIDEMIOLOGY The incidence of pulmonary embolism in the United States is estimated to be 1 case per 1000 persons per year. It is present in 60-80% of patients with DVT, even though more than half of these patients are asymptomatic. Pulmonary embolism is the third most common cause of death in hospitalized patients. Pulmonary embolism is increasingly prevalent among elderly patients. In patients younger than 55 years, the incidence of pulmonary is higher in females. In older population is greater among men than women. It is higher in black people than in whites. Whites have been 50% higher than those for people of other races (e.g. Asians, Native Americans). III. RISK FACTORS Genetic conditions that increase the risk of blood clot formation Family history of blood clotting disorders Surgery or injury (especially to the legs) or orthopedic surgery Situations in which mobility is limited, such as extended bed rest, flying or riding long distances, or paralysis Previous history of clots Older age Cancer and cancer therapy Certain medical conditions, such as heart failure, chronic obstructive pulmonary disease (COPD), high blood pressure, stroke, and inflammatory bowel disease Certain medicines, such birth control pills and estrogen replacement therapy During and after pregnancy, including after cesarean section Obesity Enlarged veins in the legs (varicose veins) Cigarette smoking IV. SIGNS AND SYMPTOMS Common symptoms include: Shortness of breath. This symptom usually appears suddenly. Trouble catching your breath happens even when resting and gets worse with physical activity. Chest pain. You may feel like you're having a heart attack. The pain is often sharp and felt when you breathe in deeply. The pain can stop you from being able to take a deep breath. You also may feel it when you cough, bend or lean over. Fainting. You may pass out if your heart rate or blood pressure drops suddenly. This is called syncope. Other symptoms that can occur with pulmonary embolism include: A cough that may include bloody or blood-streaked mucus Rapid or irregular heartbeat Lightheadedness or dizziness Excessive sweating Fever Leg pain or swelling, or both, usually in the back of the lower leg Clammy or discolored skin, called cyanosis V. TYPES Pulmonary embolism can present as acute PE or chronic PE. Acute Pulmonary Embolism is a new obstruction causing acute onset heart strain. Acute PE often needs immediate treatment with clot busters and blood thinning medications. Chronic Pulmonary Embolism is a more insidious presentation that includes heart failure with gradual progressive symptoms. Chronic PE is caused by an older residual obstruction resulting from an undissolved clot in the pulmonary circulation left over from previous acute pulmonary emboli. In addition, in a small percentage of patients, chronic PE can lead to elevated blood pressure in the pulmonary arteries over time, developing into Chronic thromboembolic pulmonary hypertension (CTEPH), a rare type of pulmonary hypertension. VI. DETECTION AND DIAGNOSTIC TEST Pulmonary embolism (PE) is often difficult to diagnose because the symptoms of PE are a lot like those of many other conditions and diseases. Along with a complete medical history and physical exam, tests used to look for a PE may include: Chest X-ray. This imaging test is used to assess the lungs and heart. Chest X-rays show information about the size, shape, contour, and anatomic location of the heart, lungs, bronchi (large breathing tubes), aorta and pulmonary arteries, and mediastinum (area in the middle of the chest separating the lungs). Ventilation-perfusion scan (V/Q scan). For this nuclear radiology test, a small amount of a radioactive substance is used to help examine the lungs. A ventilation scan evaluates ventilation, or the movement of air into and out of the bronchi and bronchioles. A perfusion scan evaluates blood flow within the lungs. Pulmonary angiogram. This X-ray image of the blood vessels is used to evaluate various conditions, such as aneurysm (bulging of a blood vessel), stenosis (narrowing of a blood vessel), or blockages. A dye (contrast) is injected through a thin flexible tube placed in an artery. This dye makes the blood vessels show up on X-ray. Computed tomography (CT or CAT scan). This is an imaging test that uses X-rays and a computer to make detailed images of the body. A CT scan shows details of the bones, muscles, fat, and organs. CT with contrast enhances the image of the blood vessels in the lungs. Contrast is a dye-like substance injected into a vein that causes the organ or tissue under study to show up more clearly on the scan. Magnetic resonance imaging (MRI). This imaging test uses a combination of a magnetic field, radio frequencies, and a computer to make detailed images of organs and structures within the body. Duplex ultrasound (US). This type of vascular ultrasound is done to assess blood flow and the structure of the blood vessels in the legs. (Blood clots from the legs often dislodge and travel into the lung.) US uses high-frequency sound waves and a computer to create images of blood vessels, tissues, and organs. Lab tests. Blood tests are used to check the blood's clotting status, including a test called D-dimer level. Other blood work may include testing for genetic disorders that may contribute to abnormal clotting of the blood. Arterial blood gasses may be checked to see how much oxygen is in the blood. Electrocardiogram (EKG). This is one of the simplest and fastest tests used to evaluate the heart. Electrodes (small, sticky patches) are placed at certain spots on the chest, arms, and legs. The electrodes are connected to an EKG machine by lead wires. The electrical activity of the heart is measured, interpreted, and printed out. VII. MANAGEMENT AND TREATMENT The length of your pulmonary embolism treatment and hospital stay will vary, depending on the severity of the clot. The main treatment for a pulmonary embolism is an anticoagulant (blood thinner). Depending on the severity of your clot and its effect on your other organs such as your heart, you may also undergo thrombolytic therapy, surgery or interventional procedures to improve blood flow in your pulmonary arteries. Vena cava filter. A small metal device placed in the vena cava (the large blood vessel that returns blood from the body to the heart) may be used to keep clots from traveling to the lungs. These filters are generally used when you can't get anticoagulation treatment (for medical reasons), develop more clots even with anticoagulation treatment, or when you have bleeding problems from anticoagulation medicines. Pulmonary embolectomy. Rarely used, this is surgery done to remove a PE. It is generally done only in severe cases when your PE is very large, you can't get anticoagulation and/or thrombolytic therapy due to other medical problems or you haven't responded well to those treatments, or your condition is unstable. Percutaneous thrombectomy. A long, thin, hollow tube (catheter) can be threaded through the blood vessel to the site of the embolism guided by X- ray. Once the catheter is in place, it's used to break up the embolism, pull it out, or dissolve it using thrombolytic medicine. Pharmacologic Treatment Anticoagulants. Also described as blood thinners, these medicines decrease the ability of the blood to clot. This helps stop a clot from getting bigger and keep new clots from forming. Examples include warfarin and heparin. Fibrinolytic therapy. Also called clot busters, these medicines are given intravenously (IV or into a vein) to break down the clot. These medicines are only used in life-threatening situations. VIII. PREVENTION Getting regular physical activity. If you can’t walk around, move your arms, legs and feet for a few minutes every hour. If you know you’ll need to sit or stand for long periods, wear compression stockings to encourage blood flow. Drinking plenty of fluids, but limiting alcohol and caffeine. Not using tobacco products. Avoiding crossing your legs. Not wearing tight-fitting clothing. Getting to a weight that’s healthy for you. Elevating your feet for 30 minutes twice a day. Talking to your provider about reducing your risk factors, especially if you or any of your family members have had a blood clot. IX. PROGNOSIS Without treatment, a pulmonary embolism is a very serious condition that can lead to permanent illness or death. Some people die suddenly or a few hours after a pulmonary embolism happens. This can happen before a provider makes a diagnosis. Your risk of dying from a PE is higher if you have a heart or lung condition. Still, with better imaging methods than providers had in the past, a pulmonary embolism is fatal for only about 1% to 3% of people who have one. About one-third of people with an undiagnosed and untreated pulmonary embolism don't survive. With treatment, your prognosis (outlook) depends on the size of the blood clot and blockages, as well as your overall health and how well your heart can pump blood. X. NURSING CONSIDERATIONS A nursing care for a pulmonary embolism can vary based on the facility. It also varies between individuals due to the tailored nature of care. Minimize risk. Minimizing risk involves reducing the chances of pulmonary embolisms and deep vein thrombosis (DVT). Manage gas exchange and oxygen therapy. Oxygen therapy may be used to help treat people who have a pulmonary embolism. Gas exchange is the process where the air in the lungs transfers to the blood to circulate throughout the body. During care in a hospital or other clinical setting, nurses can check for signs that gas exchange is occurring as it should be. To monitor gas exchange, a nurse can check for: discoloration under the fingernails, mucous membranes, or skin changes in vital signs mental acuity and other signs of hypoxia changes in lung activity signs of abnormal heart rhythms or beating patterns the presence of lumps in the calves Maintain airway clearance and breathing pattern. Airway clearance maintenance involves making sure nothing, including foreign objects, mucus, or other things, are blocking the airways. Nurses also monitor a person for signs of changes in their breathing pattern. Manage bleeding risk. Part of care for pulmonary embolisms often involves the use of anticoagulant medication as a main component of treatment. This helps prevent clots, but it can also make a person more susceptible to excessive bleeding. Nurses can help minimize the risk of bleeding events by thoroughly reviewing a person’s risk factors. They typically ask the person about preexisting conditions and the use of medications that may increase the risk of bleeding. They also likely monitor for signs of bleeding. This can include finding signs of bleeding at the injection sites or mucous membranes. Monitor diagnostic and laboratory procedures. While receiving care for a pulmonary embolism, several diagnostic tests and lab reports are needed. Part of a care plan involves a nurse monitoring the results of the tests and tailoring the care plan based on any changes. Some possible benefits of careful monitoring of labs and diagnostic tests may include: helping determine the person’s response to treatment determining the effectiveness of the treatment recognizing signs of potential complications Administer medication.One of the roles of nursing staff during treatment is to provide medications as prescribed for the continued treatment of pulmonary embolisms. ACUTE RESPIRATORY DISTRESS SYNDROME I. OVERVIEW OF THE DISEASE Acute respiratory distress syndrome (ARDS) occurs when lung swelling causes fluid to build up in the tiny elastic air sacs in the lungs. These air sacs, called alveoli, have a protective membrane, but lung swelling damages that membrane. The fluid leaking into the air sacs keeps the lungs from filling with enough air. This means less oxygen reaches the bloodstream, so the body's organs don't get the oxygen they need to work properly. This prevents enough oxygen from passing into the lungs and bloodstream. Acute respiratory distress syndrome (ARDS) usually occurs in people who are already ill due to another disease or a major injury. The most common underlying risk factor of ARDS is infection, like COVID-19, pneumonia, or sepsis. Other factors that increase your risk include fracture of multiple bones and inhaling chemical fumes or water during a near drowning. II. EPIDEMIOLOGY Acute respiratory failure due to acute respiratory distress syndrome (ARDS) ranges in incidence from 10-80/100,000/y based on where it is recorded worldwide. This is partly due to different practices and thresholds for intubation in these cases and the use of different definitions of ARDs. III. RISK FACTORS Age over 65 years Chronic lung disease Smoking Alcohol use IV. SIGNS AND SYMPTOMS The seriousness of ARDS symptoms can vary depending on what's causing them and whether there is underlying heart or lung disease. Early Symptoms include: Dyspnea Restlessness Low Blood Pressure Confusion Extreme Tiredness Change in patient behavior (Mood swing and Disorientation) Late Sign and Symptoms Severe difficulty in breathing i.e., labored, rapid breathing. Shortness of breath. Tachycardia Thick frothy sputum Metabolic acidosis Cyanosis (blue skin, lips and nails) Abnormal breath sounds, like crackles Decreased PaCo2 with respiratory alkalosis. Decreased Pa02 These are the three distinct stages of ARDS Exudative stage(0-6 days) Accumulation of excessive fluid in the lungs due to exudation(leaking to fluids) and acute injury. Hypoxemia is usually most severe during this phase of acute injury, as is injury to the endothelium(lining membrane) and epithelium(surface layer of cells). Some individual quickly recover from this first stage; many others progress after about a week into the second stage. Proliferative( fibroproliferative) stage (7-10 days) Connective tissue and other structural elements in the lungs proliferate in response to the initial injury, including development of fibrosis. The term “stiff lung” and “shock lung” frequently used to characterized this stage. Abnormally enlarged air spaces and fibrotic tissue(scarring) are increasingly apparent. Fibrotic stage (>10-14 days) Inflammation resolves. Oxygenation improved and extubation becomes possible. Lung function may continue to improve for as long as 6-12 months after onset of respiratory failure, depending on the precipitating condition and severity of initial injury. Varying levels of pulmonary fibrotic changes are possible. V. DETECTION AND DIAGNOSTIC TEST Physical exam The doctor will examine the signs of ARDS. This exam may include: Listening to your lungs through a stethoscope for abnormal breathing sounds, such as crackling Listening to your heart for a fast heart rate Checking for signs that you are having difficulty breathing, such as using muscles in your chest to help you breathe Examining your skin or lips for a bluish tone, which can signal a low blood oxygen level Examining your body for swelling or other signs of extra fluid, which may be linked to heart or kidney problems Measuring your blood pressure and oxygen levels DIAGNOSTIC TESTS AND PROCEDURES To diagnose ARDS, your doctor may have you undergo some of the following tests and procedures. Different tests may be appropriate for different ages and can include: Blood test measure the oxygen level in your blood, using a sample of blood taken from an artery. A low blood oxygen level might be a sign of ARDS. To confirm the cause of your symptoms, your doctor may also check your blood for signs of infection or a heart problem, or to see how well other organs are working. Other tests of blood oxygen levels, such as pulse oximetry, that do not require collecting a blood sample may be done. For these tests, a sensor is attached to the skin or placed on a hand or foot. Lung Imaging Test such as a chest X-ray or computerized tomography (CT) scan, create detailed images of your lungs. Lung biopsy may be done if other tests do not confirm a diagnosis. Tests for other medical conditions Other tests, such as the following, can help find the cause of your ARDS or determine whether there is another type of problem: A sputum culture can help find the cause of an infection. The culture is used to study the phlegm you have coughed up from your lungs. Bronchoscopy can diagnose a lung problem when there is no clear cause of your ARDS. As part of this test, your doctor may rinse an area of your lung to get cells and examine them under a microscope or with other tests. Urine tests detect bacterial infections or rule out kidney problems. VI. MANAGEMENT AND TREATMENT The first goal in treating ARDS is to improve the levels of oxygen in your blood. Without oxygen, your organs can't work properly. Oxygen- to get more oxygen into your bloodstream, your healthcare professional likely will use: Extra oxygen. For milder symptoms or as a short-term treatment, oxygen may be delivered through a mask that fits tightly over your nose and mouth. Mechanical ventilation. Most people with ARDS need the help of a machine to breathe. A mechanical ventilator pushes air into your lungs and forces some of the fluid out of the air sacs. Extracorporeal membrane oxygenation (ECMO) ECMO may be an option for severe ARDS when other treatment options, such as mechanical ventilation, don't work. ECMO takes over for the heart, lungs or both for a limited time while the lungs rest and heal. This treatment can help when the body can't provide the tissues with enough oxygen. The ECMO machine is an artificial heart and lung, removing blood from the body through tubes and pumping the blood through the artificial lung. This process removes carbon dioxide and adds oxygen. Then the machine pumps the blood back into the body. Because of the risks involved, it's important to discuss the pros and cons of ECMO with your healthcare tea Prone positioning For some people with ARDS, positioning on the stomach — what's known as a prone position — during mechanical ventilation may make more oxygen available to the lungs. Carefully managing the amount of IV fluids given to people with ARDS is very important. Giving too much fluid can make more fluid build up in the lungs. Giving too little fluid can strain the heart and other organs, leading to shock. Medication People with ARDS usually get medicine to: Prevent and treat infections. Ease pain and discomfort. Prevent blood clots in the legs and lungs. Reduce gastric acid reflux as much as possible. Help them feel calm or less anxious. Adequate nutritional support is vital in the treatment of ARDS. Patients with ARDS require 35 to 45 kcal/kg/day to meet caloric requirements. Enteral feeding is the first consideration; however, parenteral nutrition also may be required. Pharmacologic Treatment Antibiotics Anti-inflammatory drugs;such as corticosteroids Diuretics Drugs to raise blood pressure Anti-anxiety Muscle relaxers Inhaled drugs (Bronchodilators) VII. PREVENTION There’s no way to prevent ARDS completely. however , you may be able to lower your risk of ARD by doing the following: Seek prompt medical assistance for any trauma, infection, or illness. If you smoke, consider stopping smoking cigarettes. Try to stay away from secondhand smoke. Avoid alcohol. Chronic alcohol use may increase your mortality risk and prevent proper lung function. Get flu vaccine annually and pneumonia vaccine every 5 years. This decreases your risk of lung infections. VIII. PROGNOSIS Improved survival in recent years - mortality was 50-60% for many years, now 35-40% Improvements in supportive care, improved mechanical ventilatory management Early deaths (3 days) usually from underlying cause of ARDS Later deaths from nosocomial infections and sepsis Respiratory failure only responsible for ~ 16% of fatalities Long-term survivors usually show mild abnormalities in pulmonary function Risk factors - advanced age, CKD, CLD, chronic immunosuppression, chronic alcohol abuse Prognosis with ARDS depends primarily on the underlying cause of lung injury. In an analysis of the ARDSNet database, survival to home discharge was lowest in patients with sepsis, intermediate in patients with pneumonia, and highest in patients with trauma and ARDS. IX. NURSING INTERVENTION 1.Facilitate respiratory management such as: - Positioning of the client. - Monitoring the oxygen level, - ensure that the Endotracheal intubation is intact and patent - perform suctioning - possibly check the mechanical ventilator for any problems especially in the delivery of the oxygen 2. Performed chest physiotherapy 3. Minimize anxiety. 4. Rest - This is to minimize or to decrease oxygen consumption. RESPIRATORY FAILURE I. OVERVIEW OF THE DISEASE Respiratory failure is a condition in which the lungs cannot adequately exchange oxygen and carbon dioxide, leading to insufficient oxygen delivery to the body's tissues. This failure can be acute, developing rapidly over a short period, or chronic, progressing gradually over a longer time. Anatomy of the Lungs The lungs are paired organs located within the thoracic cavity. They are responsible for the exchange of oxygen and carbon dioxide between the blood and the atmosphere. The lungs consist of: Bronchi: Airways that branch from the trachea, leading to the smaller bronchioles. Bronchioles: Tiny tubes that end in alveoli. Alveoli: Small, balloon-like sacs where gas exchange occurs. II. EPIDEMIOLOGY International Statistics: Global Burden of Disease (GBD) 2019: Respiratory diseases, including respiratory failure, are a major cause of death worldwide. Exact figures for respiratory failure alone are difficult to isolate, as it often occurs as a complication of other conditions. National Statistics: Philippines: Data on the prevalence of respiratory failure in the Philippines is limited. However, given the high rates of respiratory infections, chronic obstructive pulmonary disease (COPD), and other respiratory conditions, it is likely a significant health issue. III. RISK Several FACTORS factors can increase the risk of Chronic lung diseases: COPD, asthma, cystic fibrosis Acute lung conditions: Pneumonia, pulmonary embolism, acute respiratory distress syndrome (ARDS) Cardiovascular diseases: Heart failure, arrhythmias Neuromuscular disorders: Muscular dystrophy, Guillain-Barré syndrome Obesity Smoking Exposure to pollutants or irritants Advanced age IV. SIGNS AND SYMPTOMS The signs and symptoms of respiratory failure can vary depending on the underlying cause and the severity of the condition. Common symptoms include: Difficulty breathing Rapid breathing Shortness of breath Chest pain or tightness Cough Fatigue Confusion or altered mental status Cyanosis (bluish discoloration of the skin or lips) V. TYPES Respiratory failure can be classified into two main types: Type I (hypoxic): Characterized by low oxygen levels in the blood (hypoxemia). This type is often caused by conditions that impair gas exchange in the lungs, such as pneumonia or ARDS. Type II (hypercapnic): Characterized by high carbon dioxide levels in the blood (hypercapnia). This type is often caused by conditions that impair the ability to remove carbon dioxide from the body, such as COPD or neuromuscular diseases. VI. DETECTION AND DIAGNOSTIC TEST The diagnosis of respiratory failure is typically based on a combination of clinical findings, medical history, and diagnostic tests. These tests may include: Blood gas analysis: Measures the levels of oxygen and carbon dioxide in the blood Chest X-ray: Can help identify underlying conditions such as pneumonia or pulmonary edema CT scan: Provides a more detailed image of the lungs Pulmonary function tests: Assess lung function Echocardiogram: Evaluates heart function VII. MANAGEMENT AND TREATMENT The treatment of respiratory failure depends on the underlying cause and the severity of the condition. It may involve: Oxygen therapy: Supplying supplemental oxygen to the lungs Mechanical ventilation: Assisting breathing with a ventilator Treatment of the underlying cause: For example, antibiotics for pneumonia or anticoagulants for pulmonary embolism Supportive care: Management of fluid balance, electrolyte imbalances, and other complications Pharmacologic Treatment Pharmacological treatment may include: Bronchodilators: To open the airways Corticosteroids: To reduce inflammation Diuretics: To treat fluid overload Sedatives and analgesics: To help with anxiety and pain VIII. PREVENTION The risk of respiratory failure can be reduced by: Quitting smoking Maintaining a healthy weight Regular exercise Getting vaccinated against respiratory infections Avoiding exposure to pollutants and irritants IX. PROGNOSIS The prognosis for respiratory failure depends on the underlying cause, the severity of the condition, and the effectiveness of treatment. Early diagnosis and appropriate management can improve outcomes. X. NURSING CONSIDERATIONS Nursing interventions for patients with respiratory failure may include: Monitoring respiratory status: Assessing respiratory rate, effort, and oxygen saturation Providing oxygen therapy: Administering oxygen as prescribed Assisting with mechanical ventilation: If necessary Monitoring vital signs and fluid balance Promoting comfort and rest Educating the patient and family about the condition and its management PNEUMONIA I. OVERVIEW OF THE DISEASE Pneumonia is an inflammatory condition of the lungs primarily affecting the alveoli, which are essential for gas exchange. It is caused by infectious agents such as bacteria, viruses, fungi, and, in some cases, by inhaling toxic substances (aspiration pneumonia). Pneumonia can range from mild to life- threatening, with the severity of the disease largely depending on the patient’s age, immune status, and underlying health conditions. The infection begins when pathogens enter the respiratory system through inhalation or aspiration. These microorganisms settle in the alveoli, where they multiply and trigger an immune response. The body’s defense mechanism—immune cells such as neutrophils and macrophages—are mobilized to the lungs. While they fight off the infection, this immune response also leads to inflammation and the accumulation of fluids (exudate) in the alveoli. This fluid interferes with normal oxygen exchange, causing the characteristic difficulty in breathing, coughing, and sometimes hypoxemia (low blood oxygen levels). There are different forms of pneumonia: Lobar Pneumonia: Affects one or more lobes of the lung, causing consolidated areas of infection visible on chest X-rays. Bronchopneumonia: Characterized by patchy areas of infection throughout the lung fields, often involving both lungs. The immune system plays a vital role in responding to pneumonia. Initially, the body recognizes the pathogen, and immune cells release inflammatory mediators to recruit more immune cells to the site of infection. These immune responses help eliminate the pathogen but can also contribute to fluid buildup and lung tissue damage. In some cases, the body’s immune response can exacerbate lung damage, leading to respiratory failure. The lungs are the primary organs affected by pneumonia. They consist of various structures essential for respiration: Bronchi: The large airways that branch off from the trachea, directing air into the lungs. Bronchioles: Smaller airways that continue from the bronchi and lead to the alveoli. Alveoli: Small, grape-like air sacs located at the end of the bronchioles where oxygen and carbon dioxide exchange occur. The alveoli are surrounded by capillaries, allowing gases to pass between the lungs and the bloodstream. In a healthy lung, oxygen from inhaled air diffuses across the alveolar walls into the capillaries, while carbon dioxide from the blood diffuses into the alveoli to be exhaled. Pneumonia disrupts this process in several ways: Inflammation: The walls of the alveoli become inflamed due to the infection, which thickens the walls and makes gas exchange less efficient. Fluid Accumulation: The alveoli fill with pus, dead cells, and exudate, further obstructing the normal exchange of gases. This reduces the amount of oxygen entering the bloodstream and leads to low oxygen levels (hypoxemia). Pleura and Pleural Space The pleura are membranes that surround the lungs. The visceral pleura is attached directly to the lungs, while the parietal pleura lines the chest wall. Between these two layers is the pleural space, which normally contains a small amount of fluid to lubricate the movement of the lungs during breathing. In some cases of pneumonia, infection or inflammation can spread to the pleura, causing pleurisy (inflammation of the pleura) or pleural effusion (accumulation of fluid in the pleural space). In pneumonia, the invading pathogens can overwhelm these defense mechanisms, allowing the infection to take hold in the lungs. Additionally, any damage to these defenses (e.g., smoking, chronic lung disease) makes individuals more susceptible to pneumonia. By disrupting normal respiratory function, pneumonia can lead to complications such as hypoxemia, respiratory failure, and sepsis, particularly in severe or untreated infection cases. II. EPIDEMIOLOGY Pneumonia is a common respiratory infection, affecting approximately 450 million people a year and occurring in all parts of the world. It is a major cause of death among all age groups, resulting in 1.4 million deaths in 2010 (7% of the world's yearly total) and 3.0 million deaths in 2016 (the 4th leading cause of death in the world). Rates are greatest in children less than five and adults older than 75 years of age. It occurs about five times more frequently in the developing world than in the developed world. South Asia and Sub-Saharan Africa have the highest prevalence of pneumonia in the world. The estimated worldwide incidence of community-acquired pneumonia varies between 1.5 to 14 cases per 1000 person-years and is affected by geography, season, and population characteristics. In the US the annual incidence is 24.8 cases per 10,000 adults, with higher rates as age increases. Pneumonia is the eighth leading cause of death and first among infectious causes of death. The mortality rate is as high as 23% for patients admitted to the intensive care unit for severe pneumonia. National Statistics According to preliminary data between January and September 2023, 5.9 percent of deaths in the Philippines were caused by pneumonia. Deaths from such illnesses significantly dropped from 2020 onwards, from its peak share of 10.1 percent in 2019. III. RISK FACTORS Pneumonia can affect individuals of any age, but certain factors increase the likelihood of developing the infection. These risk factors can be divided into categories based on age, lifestyle, existing medical conditions, and environmental exposures: 1. Age Young Children (Under 5 Years Old): Children, particularly infants, have underdeveloped immune systems, making them more susceptible to infections. Older Adults (Over 65 Years Old): The immune system weakens with age, making elderly individuals more vulnerable to infections, including pneumonia. 2. Chronic Diseases and Health Conditions Chronic Obstructive Pulmonary Disease (COPD): Conditions like emphysema and chronic bronchitis impair lung function, increasing susceptibility to pneumonia. Asthma: Individuals with asthma have more vulnerable airways and are at a higher risk of respiratory infections. Diabetes: Uncontrolled blood sugar levels can impair the immune system, increasing the risk of infections. Heart Disease: Conditions like congestive heart failure can make the lungs more susceptible to infections. Kidney Disease or Liver Disease: These conditions can weaken the body's ability to fight off infections. Immunosuppression: Individuals with compromised immune systems due to HIV/AIDS, cancer, or treatments like chemotherapy or organ transplants are at a significantly higher risk of developing pneumonia. 3. Lifestyle Factors Smoking: Smoking damages the lungs' natural defense mechanisms, such as cilia, making it easier for pathogens to reach the alveoli. Excessive Alcohol Use: Chronic alcohol use weakens the immune system and can impair the cough reflex, increasing the risk of aspiration and infection. Poor Nutrition: Malnutrition weakens the immune system, making it harder for the body to fight off infections. 4. Environmental and Occupational Exposure Air Pollution: Exposure to pollutants, chemicals, and toxins in the air can damage the lungs and increase the risk of infection. Crowded Living Conditions: Living in overcrowded environments, such as shelters or group homes, increases the risk of exposure to respiratory infections. Exposure to Toxic Substances: Workers in industries where they are exposed to chemicals or dust (e.g., mining, construction) have an increased risk of lung infections, including pneumonia. 5. Recent Illnesses or Hospitalization Recent Respiratory Infection: People recovering from colds, flu, or other respiratory infections are more vulnerable to developing pneumonia. Hospitalization: Prolonged hospital stays, especially in intensive care units, increase the risk of hospital-acquired pneumonia (HAP), particularly if the patient is on a ventilator, leading to ventilator- associated pneumonia (VAP). Aspiration: Individuals who aspirate food, liquids, or vomit into their lungs (due to stroke, neurological disorders, or impaired swallowing) have a higher risk of aspiration pneumonia. 6. Vaccination Status Lack of Vaccination: Not receiving vaccines such as the pneumococcal vaccine, influenza vaccine, or vaccines for childhood illnesses (like measles or whooping cough) increases the risk of developing pneumonia, especially in vulnerable groups like children and the elderly. IV. SIGNS AND SYMPTOMS Pneumonia in adults can range from mild to severe, depending on the cause of the infection, the person's overall health, and the presence of underlying medical conditions. Common Symptoms Cough: Often productive, meaning it produces mucus or phlegm. The mucus may be green, yellow, or tinged with blood. Fever: High fever, often accompanied by chills and sweating. Shortness of Breath: Difficulty breathing, especially during physical activity. Chest Pain: Sharp or stabbing pain that worsens with deep breathing or coughing (pleuritic chest pain). Fatigue: Extreme tiredness and low energy levels. Confusion: Especially in older adults, pneumonia can cause confusion or changes in mental awareness. Loss of Appetite: A general feeling of illness, often accompanied by reduced interest in eating. Less Common Symptoms Headache: Due to fever and systemic infection. Muscle or Joint Pain: Sometimes associated with the body's immune response to infection. Nausea, Vomiting, or Diarrhea: These gastrointestinal symptoms can sometimes accompany respiratory infections. Pneumonia in infants and young children can present differently from adults. Babies, especially, may not show the typical signs and symptoms seen in older individuals. Common Symptoms Fever: Often the most noticeable symptom. Babies may have a high or low-grade fever. Rapid or Labored Breathing: Fast breathing (tachypnea) is a common sign. Parents may notice the baby is breathing faster than usual, or there may be visible chest retractions (the skin pulls in between the ribs or under the ribcage during breathing). Grunting or Wheezing: Babies may make grunting noises when breathing or have wheezing sounds. Flaring Nostrils: A sign of breathing difficulty. Cough: This may be mild or absent in some babies, but if present, it could be dry or produce mucus. Irritability or Fussiness: Babies may cry more than usual and be difficult to soothe. Lethargy: The baby may appear unusually tired, less responsive, or sleepy. Less Common Symptoms Poor Feeding: A baby with pneumonia may refuse to eat or drink as much as usual. Vomiting: Some babies may vomit due to the infection. Bluish Color of the Lips or Fingernails: A sign of low oxygen levels, this is a serious symptom that requires immediate medical attention (cyanosis). Severe Symptom Cyanosis: Bluish tint to the lips, skin, or fingernails, indicating insufficient oxygen. Severe Difficulty Breathing: Labored breathing, inability to speak or cry (in babies), or respiratory distress. High Fever: Persistently high fever despite treatment. Confusion or Unresponsiveness: Especially in elderly adults or very young children. V. TYPES 1. Community-Acquired Pneumonia (CAP): Pneumonia contracted outside of healthcare facilities or hospitals. 2. Hospital-Acquired Pneumonia (HAP): Pneumonia acquired during a hospital stay, at least 48 hours after being admitted, but not present at the time of admission. 3. Ventilator-Associated Pneumonia (VAP): A type of pneumonia that occurs in people on mechanical ventilation (usually in an intensive care unit). 4. Aspiration Pneumonia: Pneumonia caused by inhaling food, liquid, vomit, or foreign objects into the lungs. 5. Atypical Pneumonia: Pneumonia caused by certain bacteria or organisms that produce milder, gradual symptoms compared to typical bacterial pneumonia. 6. Fungal Pneumonia: Pneumonia caused by fungi, often affecting individuals with weakened immune systems or those living in regions where certain fungi are more prevalent. 7. Lobar Pneumonia: Pneumonia that affects one or more lobes of the lung. 8. Bronchopneumonia: Pneumonia that affects patches of the lungs, typically in the bronchi and bronchioles, resulting in scattered areas of infection. 9. Pneumocystis Pneumonia (PCP): A form of pneumonia caused by the fungus Pneumocystis jirovecii, typically occurring in immunocompromised individuals , or those people with HIV/AIDS. VI. DETECTION AND DIAGNOSTIC TEST Detecting and diagnosing pneumonia involves a combination of clinical assessments, imaging studies, laboratory tests, and sometimes specialized diagnostic procedures. These methods help determine the presence of pneumonia, its severity, and the causative pathogen, allowing for appropriate treatment. 1. Medical History and Physical Examination Medical History: Symptoms such as cough, fever, difficulty breathing, chest pain and fatigue, recent illnesses, exposure to infectious agents, and any underlying health conditions are asked during the assessment. Physical Examination: During the physical exam, the healthcare provider will listen to the lungs using a stethoscope. Common findings in pneumonia include: o Crackles (Rales): Abnormal, crackling lung sounds due to fluid in the alveoli. o Diminished Breath Sounds: Reduced air movement in affected areas of the lung. o Dullness to Percussion: Tapping on the chest may produce a dull sound, indicating fluid accumulation. 2. Imaging Studies Chest X-ray: A chest X-ray is the most commonly used imaging tool to diagnose pneumonia. It can reveal: o Lobar Consolidation: A well-defined area of the lung affected by infection, typical in lobar pneumonia. o Patchy Infiltrates: Scattered areas of infection seen in bronchopneumonia. o Pleural Effusion: Fluid accumulation around the lungs, sometimes seen with pneumonia. While a chest X-ray helps confirm pneumonia, it may not identify the specific pathogen causing the infection. CT Scan: In more complex cases, or if the chest X-ray results are inconclusive, a computed tomography (CT) scan of the chest may be ordered. CT scans provide more detailed images and can detect complications such as abscesses or pleural effusions. 3. Laboratory Tests Several lab tests are commonly used to detect pneumonia and identify the causative pathogen: Complete Blood Count (CBC): A CBC can help determine the severity of infection by measuring the levels of white blood cells (WBCs). Elevated WBCs, particularly neutrophils, suggest a bacterial infection, while a normal or low WBC count may indicate a viral infection. Sputum Culture: If the patient has a productive cough, a sputum sample (mucus from the lungs) may be collected and sent to the lab for a culture. This test helps identify the bacteria causing pneumonia and their antibiotic sensitivities, guiding treatment. Blood Cultures: In severe cases, particularly when there is concern about sepsis (infection spreading to the bloodstream), blood cultures may be done to check for bacteria in the blood. C-reactive Protein (CRP) and Procalcitonin: These markers help assess the level of inflammation in the body. Elevated CRP and procalcitonin levels often indicate bacterial infections, which can help distinguish between bacterial and viral pneumonia. 4. Pulse Oximetry and Arterial Blood Gases (ABGs) Pulse Oximetry: This non-invasive test measures the level of oxygen in the blood using a sensor placed on the finger. Low oxygen saturation may indicate that the lungs are not adequately transferring oxygen to the blood due to pneumonia. Arterial Blood Gases (ABGs): In more severe cases, especially when the patient has difficulty breathing, an ABG test may be performed to measure oxygen and carbon dioxide levels in the blood. This test helps assess the severity of respiratory impairment and the need for oxygen therapy or mechanical ventilation. 5. Specialized Diagnostic Tests Bronchoscopy: In some cases, especially when the diagnosis is uncertain or the pneumonia is not responding to standard treatments, a bronchoscopy may be performed. This involves inserting a thin, flexible tube with a camera into the airways to directly visualize the lungs. During the procedure, fluid or tissue samples can be collected for analysis. Thoracentesis: If there is fluid around the lungs (pleural effusion), a thoracentesis may be done to remove and analyze the fluid. This test can help identify the cause of the fluid buildup and determine if the pneumonia is caused by an infection, cancer, or another condition. Polymerase Chain Reaction (PCR) Testing: PCR tests can detect genetic material from viruses, bacteria, or fungi in a sample of blood, sputum, or other bodily fluids. It is particularly useful for diagnosing viral pneumonia or infections caused by hard-to-culture organisms like Mycoplasma pneumoniae or Legionella. Urine Antigen Tests: For certain types of bacterial pneumonia, such as Legionella pneumophila and Streptococcus pneumoniae, urine antigen tests can quickly detect the presence of bacterial antigens, allowing for a rapid diagnosis. 6. Other Diagnostic Considerations Viral Testing: If viral pneumonia is suspected (especially during flu season or COVID-19 outbreaks), tests such as PCR or rapid antigen tests for influenza or COVID-19 may be conducted. Tuberculin Skin Test or IGRA: In regions where tuberculosis (TB) is common, or in patients with risk factors for TB, additional testing may be necessary to rule out TB-related pneumonia. VII. MANAGEMENT AND TREATMENT Community-Acquired Pneumonia (CAP) 1. Antibiotic Therapy: Outpatient Treatment (for mild cases): Empiric antibiotics, such as: o Amoxicillin o Macrolides (e.g., azithromycin) o Doxycycline (for patients with penicillin allergies) Inpatient Treatment (moderate to severe cases): o Beta-lactams (e.g., ceftriaxone) o Macrolides or fluoroquinolones for broader coverage. o For severe CAP, IV antibiotics like ceftriaxone and azithromycin may be used. 2. Antiviral or Antifungal Therapy (if viral or fungal pathogens are identified): Antivirals (e.g., oseltamivir for influenza-related pneumonia). Antifungal therapy (e.g., fluconazole or amphotericin B) for fungal pneumonia. 3. Adjunctive Therapies: Oxygen Therapy: For patients with low blood oxygen levels to maintain adequate oxygenation. Intravenous Fluids: To prevent dehydration and maintain electrolyte balance. Nutritional Support: In hospitalized patients, especially those at risk for malnutrition. Mechanical Ventilation: For patients with severe pneumonia and respiratory failure. Ventilator-Associated Pneumonia (VAP) 1. Antibiotic Therapy: Empiric broad-spectrum antibiotics are used to cover multidrug- resistant organisms (e.g., Pseudomonas aeruginosa, MRSA): o Piperacillin-tazobactam or cefepime for Gram-negative coverage. o Vancomycin or linezolid for MRSA. Once cultures are available, antibiotic therapy is tailored to target the specific pathogen. 2. Adjunctive Therapies: Oxygen Therapy and Mechanical Ventilation: If patients are already on a ventilator, adjustments to ventilation settings ensure adequate oxygenation and carbon dioxide elimination. Hydration and Electrolyte Balance: Through IV fluids and monitoring. Nutritional Support: Enteral feeding (via a feeding tube) is often required to maintain nutritional status. General Management 1. Oxygen therapy is essential for pneumonia patients who have low blood oxygen levels (hypoxemia). The goal is to maintain adequate oxygenation and prevent organ damage due to lack of oxygen. 2. Intravenous Fluids. Pneumonia can lead to dehydration due to fever, increased respiratory rate, and reduced oral intake. Types of IV fluids commonly used include normal saline or lactated Ringer's solution. Intravenous (IV) fluids are used to: Maintain proper hydration. Correct electrolyte imbalances. Support blood pressure in severe cases or if sepsis is a concern. 3. Mechanical Ventilators. For patients with severe pneumonia leading to respiratory failure, mechanical ventilation may be required. This is typically used in intensive care units (ICUs) when patients are unable to maintain adequate oxygenation and carbon dioxide levels on their own. Mechanical ventilation can help: Improve oxygen delivery to the lungs. Support breathing until the infection is controlled. Reduce the work of breathing in critically ill patients. Nutritional Support 4. Nutritional Support. Proper nutrition is crucial, particularly for hospitalized pneumonia patients. Nutritional support helps to: Maintain energy levels and immune function. Prevent malnutrition, which can delay recovery. Provide essential nutrients to help the body fight infection and repair damaged tissues. PHARMACOLOGIC TREATMENT 1. Antibiotics (for bacterial pneumonia): CAP: Empiric therapy includes beta-lactams (e.g., amoxicillin or ceftriaxone), macrolides (e.g., azithromycin), or fluoroquinolones (e.g., levofloxacin). VAP: Broad-spectrum antibiotics targeting drug-resistant pathogens such as piperacillin-tazobactam, vancomycin, or linezolid. 2. Antivirals (for viral pneumonia): Oseltamivir or zanamivir for influenza. Antivirals for COVID-19 (e.g., remdesivir). 3. Antifungals (for fungal pneumonia): Fluconazole or amphotericin B for fungal infections like histoplasmosis or coccidioidomycosis. 4. Symptom Management: Antipyretics: Such as acetaminophen or ibuprofen for fever and pain relief. Cough Suppressants: To manage persistent cough. Bronchodilators: To improve airflow in patients with obstructive airway diseases. VIII. PREVENTION 1. Vaccination: Pneumococcal Vaccine: Prevents Streptococcus pneumoniae infections, recommended for children, the elderly, and those with chronic conditions. 2. Influenza Vaccine: Reduces the risk of flu-related pneumonia. COVID-19 Vaccine: Prevents severe respiratory complications from COVID-19, including pneumonia. 3. Good Hygiene Practices: Regular handwashing and respiratory hygiene (covering coughs and sneezes). Avoiding close contact with sick individuals. 4. Smoking Cessation: Reduces the risk of developing pneumonia and other respiratory infections. 5. Healthy Lifestyle: Maintaining good nutrition and regular exercise to support the immune system. 6. Hospital Infection Control (for VAP): Regular oral care for ventilated patients. Elevating the head of the bed to prevent aspiration. Strict adherence to aseptic techniques during intubation. IX. PROGNOSIS The prognosis for pneumonia varies depending on factors such as the type of pneumonia, the patient’s age, and underlying health conditions. CAP: Most patients recover fully with prompt antibiotic treatment. Mortality rates are low for young, healthy individuals but can be higher in the elderly or those with chronic illnesses. VAP: The prognosis is more serious due to drug-resistant pathogens and the patient’s already compromised state. The mortality rate is higher, especially in critically ill patients. Complications: Include respiratory failure, sepsis, pleural effusion, lung abscess, and death in severe cases. The prognosis for community-acquired pneumonia is determined by three main factors: the patient’s age; their overall state of health (presence of any comorbidities); and the severity or seriousness of the disease presentation. The mortality in patients treated on an outpatient basis is generally less than 1%, it ranges from 5% to 15% in those admitted to a ward, but it reaches between 20% and 50% in patients who are admitted to an intensive care unit (ICU). There are several risk factors associated with mortality in pneumonia: bacteraemia, or the presence of microorganisms in the blood; admission to an ICU; chronic comorbidities (particularly neurological diseases); and pneumonia caused by an antibioticresistant pathogen (Staphylococcus aureus, Pseudomonas aeruginosa, Enterobacteriaceae). The rate of hospital readmission ranges between 7% and 12% in patients with CAP. In most cases the main reason for readmission is due to an escalation associated with chronic diseases; primarily cardiovascular, pulmonary or neurological conditions. X. NURSING CONSIDERATIONS 1. Assessment: Regularly assess vital signs (e.g., respiratory rate, oxygen saturation, temperature) to monitor the patient’s status. Monitor for worsening symptoms, such as increased respiratory distress or confusion, which may indicate hypoxemia. Assess lung sounds for crackles, diminished breath sounds, or changes indicating improvement or deterioration. 2. Oxygen Therapy: Administer oxygen as prescribed, monitoring for effectiveness. Adjust oxygen delivery methods based on patient response, from nasal cannula to high-flow oxygen or mechanical ventilation in severe cases. 3. Airway Clearance: Encourage deep breathing and coughing exercises to help clear secretions. Use chest physiotherapy and suctioning as needed to maintain airway patency. 4. Hydration and Nutrition: Ensure adequate fluid intake to help thin mucus and maintain hydration. Monitor nutritional intake and consider supplemental nutrition if necessary. 5. Patient Education: Teach patients about medication adherence, particularly the importance of completing the full course of antibiotics. Educate on preventive measures, including vaccines and smoking cessation. Emphasize good hand hygiene and respiratory etiquette. 6. Infection Control: Implement isolation protocols for patients with contagious pneumonia (e.g., influenza, COVID-19) to prevent the spread of infection. Follow strict hygiene and aseptic practices when caring for patients on mechanical ventilation to prevent VAP. 7. Emotional Support: Provide reassurance and emotional support, especially for patients with severe pneumonia or those requiring prolonged hospitalization. Address concerns and fears about treatment, recovery, and potential complications. RESPIRATORY PANDEMICS I. OVERVIEW OF THE DISEASE Illnesses caused by respiratory viruses like COVID-19, flu, and RSV can make anyone sick. However, there are a range of risk factors that can increase a person’s chances of getting very sick (severe illness). Generally, people at higher risk of severe illness from respiratory viruses are older adults, young children, people with compromised immune systems, people with disabilities, and pregnant people. II. EPIDEMIOLOGY The global epidemiology of respiratory pandemics, such as COVID-19, demonstrates the rapid spread of viral infections due to high transmission rates via respiratory droplets. Internationally, densely populated areas and global travel hubs became hotspots for early outbreaks. The pandemic led to widespread morbidity and mortality, particularly in populations with underlying health conditions. Governments worldwide implemented public health measures such as lockdowns, mask mandates, and vaccination campaigns to mitigate the spread. By mid-2023, the global response to the COVID-19 pandemic saw over 770 million confirmed cases and over 6.9 million deaths, with varying outcomes depending on healthcare infrastructure, vaccine availability, and public compliance. In the Philippines, the pandemic significantly impacted the healthcare system and economy, with over 4 million confirmed cases and approximately 66,000 deaths by 2023. The densely populated urban centers like Metro Manila experienced the highest case rates, exacerbated by socioeconomic disparities and challenges in healthcare accessibility. The government implemented strict quarantine measures, including curfews, lockdowns, and a phased vaccine rollout starting in early 2021. Despite challenges in logistics and vaccine hesitancy, the country achieved higher vaccination rates, which contributed to a decline in severe cases by the end of 2022. Public health measures and community resilience were crucial in managing the pandemic's local impact. III. RISK FACTORS Older adults- As people get older, their immune systems do not work as well. Young children- Young children, particularly infants, have immune systems that are still developing. People with weakened immune systems- People with weakened immune systems (immunocompromise) have lower defenses against infections, and their bodies may have a harder time building lasting protection from past immunization or infection. People with disabilities- people with disabilities are more likely to have underlying medical conditions, live in congregate settings, or experience factors Pregnant people-Changes in the immune system, heart, and lungs during pregnancy can raise the risk of getting very sick from respiratory viruses. IV. SIGNS AND SYMPTOMS V. TYPES FLU COVID-19 RSV (RESPIRATORY SYNCYTIAL VIRUS) ADENOVIRUS RHINOVIRUS/ENTEROVIRUS (COMMON COLD) PARAINFLUENZA PARVOVIRUS B19 (FIFTH) DISEASE VI. DETECTION AND DIAGNOSTIC TEST ANTIGEN TEST- antigen tests are designed for the rapid diagnoses of active infection primarily by detecting the nucleocapsid protein antigen of the SARS-CoV-2 virus (the virus that causes COVID-19) from nasal swabs or similar clinical specimens. NUCLEIC ACID AMPILIFICATION TESTS (NAATS)- NAATs detect genetic material (nucleic acids). NAATs for SARS-CoV-2 specifically identify the RNA (ribonucleic acid) sequences that comprise the genetic material of the virus. NAATs for SARS-CoV-2 test specimens from either the upper or lower respiratory tract. VII. MANAGEMENT AND TREATMENT 1. Public Health Measures- such as quarantine, social distancing, use of personal protective equipment (PPE), hand hygiene and sanitation, vaccination, and public education. 2. Medical Management- Antivirals or antibacterial therapy. oxygen therapy, anti-inflammatory medications, and immunotherapy 3. Critical Care Management- Mechanical ventilation, Extracorporeal Membrane Oxygenation (ECMO), prone positioning, Continuous Renal Replacement Therapy (CRRT) PHARMACOLOGIC TREATMENT Antiviral Medications INFLUENZA-SPECIFIC ANTIVIRALS: Oseltamivir (Tamiflu), Zanamivir (Relenza), Peramivir (Rapivab) Baloxavir marboxil (Xofluza) COVID-19 SPECIFIC ANTIVIRALS: Remdesivir, Paxlovid, Molnupiravir Corticosteroids- Dexamethasone, Prednisone or Hydrocortisone Antibiotics- Azithromycin, Amoxicillin-clavulanate, Levofloxacin or Moxifloxaci, Ceftriaxone Bronchodilators- Albuterol, Ipratropium Adjunctive Therapies- Vitamin D, C, and Zinc VIII. PREVENTION 1. Vaccination 2. Personal Protective Measures 3. Social and Behavioral Measures 4. Environmental Measures 5. Travel Restrictions and Screening 6. STRENGTHENING HEALTH CARE SYSTEM IX. PROGNOSIS The prognosis during a respiratory pandemic depends on factors like the virulence of the pathogen, patient age, underlying health conditions, and access to healthcare. Most individuals experience mild symptoms and recover within 1–2 weeks, especially if they are vaccinated, while high-risk groups such as the elderly and those with comorbidities face a higher risk of severe illness, complications, and death. Timely medical interventions, including antivirals, oxygen therapy, or mechanical ventilation, improve outcomes, but overwhelmed healthcare systems can lead to worse prognoses. Long-term complications, such as respiratory issues or "long COVID," may persist in some survivors. X. NURSING CONSIDERATIONS Nursing considerations during a respiratory pandemic focus on infection control, patient assessment, and supportive care. Nurses must ensure strict adherence to PPE guidelines, including proper donning and doffing procedures, to prevent the spread of infection. Regular monitoring of respiratory status, including oxygen saturation and lung sounds, is crucial, especially in patients with severe symptoms. Nurses should administer medications like antivirals or oxygen therapy as prescribed, while also providing emotional support and education on isolation, hand hygiene, and symptom management. PULMONARY HYPERTENSION I. OVERVIEW OF THE DISEASE Pulmonary hypertension (PH) is a condition characterized by elevated blood pressure within the pulmonary arteries, which transport blood from the heart to the lungs.Pulmonary hypertension is a type of high blood pressure that affects the arteries in the lungs and the right side of the heart. Over time, this increased pressure can lead to right ventricular hypertrophy (thickening of the heart's right ventricle) and heart failure. There are various types of PH, and it is classified based on the underlying cause. Anatomy of the Affected Organ: The pulmonary arteries are the blood vessels that carry blood from the right side of the heart to the lungs for oxygenation. The right ventricle pumps deoxygenated blood into the pulmonary arteries. When blood pressure increases in the pulmonary arteries, the right side of the heart must work harder to pump blood through the lungs, leading to heart strain and damage over time. II. EPIDEMIOLOGY International Statistics: The global prevalence of pulmonary hypertension is estimated to be between 1–2% in the general population but rises to 10% in individuals over 65 years old. It’s more common in women than in men, with the ratio being about 1.8:1. Pulmonary arterial hypertension (PAH) is a subset of PH, with an estimated incidence of 15–50 cases per million globally. National Statistics (Philippines): Data on PH in the Philippines is limited, but available hospital records suggest a rising trend in PH diagnoses. In Southeast Asia, the prevalence of PH may mirror the global trend, though more epidemiological studies are needed for precise estimates. III. RISK FACTORS Pulmonary hypertension is usually diagnosed in people ages 30 to 60. Growing older can I.increase OVERVIEW the risk OF THE DISEASE of developing Group 1 pulmonary hypertension, called pulmonary arterial hypertension (PAH). PAH from an unknown cause is more common in younger adults. Other things that can raise the risk of pulmonary hypertension are: A family history of the condition. Being overweight. Smoking. Blood-clotting disorders or a family history of blood clots in the lungs. Exposure to asbestos. A heart problem that you're born with, called a congenital heart defect. Living at a high altitude. Use of certain drugs, including some weight-loss medicines and illegal drugs such as cocaine or methamphetamine IV. SIGNS AND SYMPTOMS The symptoms of pulmonary hypertension develop slowly. You may not notice them for months or even years. Symptoms get worse as the disease progresses. Pulmonary hypertension symptoms include: Shortness of breath, at first while exercising and eventually while at rest. Blue or gray skin color due to low oxygen levels. Depending on your skin color, these changes may be harder or easier to see. Chest pressure or pain. Dizziness or fainting spells. Fast pulse or pounding heartbeat. Fatigue. Swelling in the ankles, legs and belly area. Shortness of breath is the most common symptom of pulmonary hypertension. But it may be caused by other health conditions such as asthma. See a health care professional for an accurate diagnosis. V. TYPES Group 1: Pulmonary Arterial Hypertension WHO Group 1 refers to pulmonary arterial hypertension, which is caused when the arteries in the lungs become narrowed, thickened or stiff. The right side of the heart must work harder to push blood through these narrowed arteries. This extra stress can cause the heart to lose its ability to pump enough blood through the lungs to meet the needs of the rest of the body. There are several types of PAH. Idiopathic PAH is PAH that occurs without a clear cause. Heritable PAH (HPAH is linked to genes that are inherited from family members. PAH can also develop in association with other medical conditions including congenital heart disease, liver disease, HIV a lnd connective tissue diseases — such as scleroderma and lupus. PAH can even be associated with past or present drug use, such as the use of methamphetamine or certain diet pills. While there are treatment options for PAH, there is no known cure. Group 2: Pulmonary Hypertension Due to Left Heart Disease WHO Group 2 includes PH due to left heart disease. In this group of PH, the arteries and lungs are not as thick or stiff as WHO Group 1, but there are problems with how the heart squeezes or relaxes, or problems with the valves on the left side of the heart. Because of this, the left heart is unable to keep up with the blood returning from the lungs — causing a “backup” of blood which raises pressure in the lungs. WHO Group 2 is the most common form of PH. Group 3: Pulmonary Hypertension Due to Lung Disease WHO Group 3 includes PH due to chronic lung disease and/or hypoxia (low oxygen levels). These lung diseases include obstructive lung disease where the lung airways narrow and make it harder to exhale (e.g. COPD or emphysema); restrictive lung disease in which the lungs have a tough time expanding when one inhales (e.g. interstitial lung disease or pulmonary fibrosis); sleep apnea; and living in an area of high altitude for a long period of time. Arteries in the lungs tighten so that blood can only go to areas of the lungs that are receiving the most air and oxygen. This tightening leads to high blood pressure throughout the lungs. Group 4: Pulmonary Hypertension Due to Chronic Blood Clots in the Lungs WHO Group 4 is called chronic thromboembolic pulmonary hypertension (CTEPH). CTEPH can occur when the body is not able to dissolve a blood clot in the lungs. This can lead to scar tissue in the blood vessels of the lungs, which blocks normal blood flow and makes the right side of the heart work harder. This type of PH is unique because it can potentially be cured through pulmonary thromboendarterectomy (PTE) surgery to remove the blood clots. However, not all CTEPH patients are eligible for this surgery. A drug is also available for CTEPH patients if a doctor determines that a patient is not a candidate for the PTE surgery or if PH remains after the surgery. Group 5: Pulmonary Hypertension Due to Unknown Causes WHO Group 5 is where PH is secondary to other diseases in ways that are not well understood. These associated conditions include, but are not limited to, sarcoidosis, sickle cell anemia, chronic hemolytic anemia, splenectomy (spleen removal) and certain metabolic disorders. VI. DETECTION AND DIAGNOSTIC TEST Echocardiography: The first line of investigation; it estimates pulmonary artery pressure and assesses right ventricular function. Right heart catheterization: A definitive diagnostic test, measuring pulmonary artery pressure directly. Electrocardiogram (ECG): May show signs of right ventricular hypertrophy or strain. Pulmonary function tests (PFTs): To assess lung function. Ventilation/perfusion (V/Q) scan: To check for blood clots. Six-minute walk test: Measures exercise tolerance. Blood tests: To identify underlying causes, such as connective tissue diseases or HIV. VII. MANAGEMENT AND TREATMENT Pharmacologic Treatment: Endothelin receptor antagonists (ERAs): Bosentan, ambrisentan. Phosphodiesterase-5 inhibitors: Sildenafil and tadalafil to relax pulmonary blood vessels. Prostacyclins: Epoprostenol, treprostinil, or iloprost to dilate pulmonary arteries. Soluble guanylate cyclase (sGC) stimulators: Riociguat to reduce pressure in pulmonary arteries. Calcium channel blockers: Nifedipine or diltiazem for patients who respond to vasoreactivity testing. Anticoagulants: For patients with chronic thromboembolic pulmonary hypertension (CTEPH). Diuretics: To manage fluid overload. Non-Pharmacologic Treatment: Oxygen therapy: For patients with low blood oxygen levels. Pulmonary rehabilitation: Exercise programs to improve physical function. Surgical treatments: o Atrial septostomy: A procedure to reduce pressure on the right heart. o Lung transplantation: For severe cases unresponsive to medical therapy. VIII. PREVENTION Early detection and management of risk factors, such as treating lung diseases and heart conditions, can reduce the likelihood of developing pulmonary hypertension. Lifestyle changes, including avoiding smoking and maintaining a healthy weight, are important in preventing PH. IX. PROGNOSIS The prognosis of pulmonary hypertension depends on the underlying cause, the severity of symptoms, and the patient’s response to treatment. PAH, if left untreated, can have a poor prognosis, with a median survival of 2.8 to 3 years from diagnosis. With modern treatments, survival and quality of life have improved significantly. X. NURSING CONSIDERATIONS Monitor vital signs, particularly oxygen saturation, blood pressure, and heart rate. Administer prescribed medications on schedule, ensuring proper patient education on drug use. Educate the patient about the importance of lifestyle modifications, including diet, exercise, and avoiding high-altitude environments. Monitor for signs of right-sided heart failure, such as weight gain, edema, and shortness of breath. Coordinate care with other healthcare providers, ensuring routine follow-ups, medication adherence, and monitoring of disease progression. Psychosocial support: Address the emotional and psychological impact of living with a chronic disease. PNEUMOTHORAX I. OVERVIEW OF THE DISEASE A pneumothorax is a collection of air outside the lung but within the pleural cavity. It occurs when air accumulates between the parietal and visceral pleurae inside the chest. The air accumulation can apply pressure on the lung and make it collapse. The degree of collapse determines the clinical presentation of pneumothorax. Air can enter the pleural space by two mechanisms, either by trauma causing communication through the chest wall or from the lung by rupture of the visceral pleura. There are two types of pneumothorax: traumatic and atraumatic. The two subtypes of atraumatic pneumothorax are primary and secondary. A primary spontaneous pneumothorax (PSP) occurs automatically without a known eliciting event, while a secondary spontaneous pneumothorax (SSP) occurs after an underlying pulmonary disease. A traumatic pneumothorax can be the result of blunt or penetrating trauma. Pneumothoraces can be even further classified as simple, tension, or open. A simple pneumothorax does not shift the mediastinal structures, as does a tension pneumothorax. Open pneumothorax is an open wound in the chest wall through which air moves in and out. II. EPIDEMIOLOGY Pneumothorax, the condition where air enters the space between the lung and chest wall, affects individuals globally. While international research offers valuable insights into its epidemiology, data on the Philippines remains scarce, hindering our understanding of its true impact. The incidence of non-traumatic pneumothorax is 7.4 to 18 per 100000 people per year. It is much higher in smokers. Primary spontaneous pneumothorax often affects young males, tall and thin built, often smokers. The incidence of recurrence is 20 to 60% in the first 3 years after the first episode. Secondary spontaneous pneumothoraces also occurs in patients with underlying lung disease; thus epidemiology varies greatly. Unfortunately, comprehensive data on pneumothorax in the Philippines is lacking due to factors such as limited reporting, underdiagnosis, and a lack of dedicated studies. This data gap hinders efforts to understand the true burden of pneumothorax in the country, impacting resource allocation and healthcare planning. Furthermore, without accurate data, it's difficult to develop targeted prevention strategies and improve diagnostic approaches for this condition. III. RISK FACTORS In general, men are far more likely to have a pneumothorax than women are. The type of pneumothorax caused by ruptured air blisters is most likely to occur in people between 20 and 40 years old, especially if the person is very tall and underweight. Smoking - The risk increases with the length of time and the number of cigarettes smoked, even without emphysema. Genetics - Certain types of pneumothorax appear to run in families. Previous pneumothorax - Anyone who has had one pneumothorax is at increased risk of another. IV. SIGNS AND SYMPTOMS Common symptoms of a collapsed lung include: Sharp chest or shoulder pain, made worse by a deep breath or a cough Shortness of breath Nasal flaring (from shortness of breath) A larger pneumothorax causes more severe symptoms, including: Bluish color of the skin due to lack of oxygen Chest tightness Lightheadedness and near fainting Easy fatigue Abnormal breathing patterns or increased effort of breathing Rapid heart rate Shock and collapse V. TYPES Primary spontaneous pneumothorax- occurs in young people (aged 15-34) without any history of lung disease. Secondary spontaneous pneumothorax - typically occurs in people who have pre-existing connective tissue disorders (such as Marfan’s Syndrome) or lung diseases. Traumatic pneumothorax - occurs from a traumatic injury to the chest or wall of the lung, usually from an accident or through a contact sport. Tension pneumothorax - a life-threatening condition that requires immediate treatment. Air cannot escape the pleural space, so every time the person breathes in, more air enters the space, increasing the pressure on the lung and heart. VI. DETECTION AND DIAGNOSTIC TEST Chest X-ray In the supine position, the juxtacardiac area, the lateral chest wall, and the subpulmonic region are the best areas to search for evidence of pneumothorax. The presence of a deep costophrenic angle on a supine film may be the only sign of pneumothorax; this has been termed the deep sulcus sign. Typically they demonstrate: visible visceral pleural edge is seen as a very thin, sharp white line. no lung markings are seen peripheral to this line. Computerized Tomography (CT) scan CT scanning may prove helpful in predicting the rate of recurrence in patients with spontaneous pneumothorax. The authors found that patients with larger or more numerous blebs, as demonstrated on thoracic CT, are more likely to experience recurrences. it may be needed to provide more-detailed images. Ultrasound imaging It depends on lung point and is regarded as a gold standard with a specificity of 100%. For the patients with pneumothorax, as the probe moves laterally along the chest wall, a specific area (lung point) can be detected. VII. MANAGEMENT AND TREATMENT Observation If only a small portion of your lung is collapsed, your doctor may simply monitor your condition with a series of chest X-rays until the excess air is completely absorbed and your lung has re-expanded. This may take several weeks. Needle aspiration A hollow needle with a small flexible tube (catheter) is inserted between the ribs into the air-filled space that's pressing on the collapsed lung. Then the doctor removes the needle, attaches a syringe to the catheter and pulls out the excess air. The catheter may be left in for a few hours to ensure the lung is re-expanded and the pneumothorax does not recur. Chest tube insertion A flexible chest tube is inserted into the air-filled space and may be attached to a one-way valve device that continuously removes air from the chest cavity until your lung is re-expanded and healed. Non Surgical Repair If a chest tube doesn't re-expand your lung, nonsurgical options to close the air leak may include: Using a substance to irritate the tissues around the lung so that they'll stick together and seal any leaks. This can be done through the chest tube, but it may be done during surgery. Drawing blood from your arm and placing it into the chest tube. The blood creates a fibrinous patch on the lung (autologous blood patch), sealing the air leak. Passing a thin tube (bronchoscope) down your throat and into your lungs to look at your lungs and air passages and placing a one-way valve. The valve allows the lung to re-expand and the air leak to heal. Surgery sometimes may be necessary to close the air leak. In most cases, the surgery can be performed through small incisions, using a tiny fiber-optic camera and narrow, long-handled surgical tools. The surgeon will look for the leaking area or ruptured air blister and close it off. Rarely, the surgeon will have to make a larger incision between the ribs to get better access to multiple or larger air leaks. Ongoing care, you may need to avoid certain activities that put extra pressure on your lungs for a time after your pneumothorax heals. Examples include flying, scuba diving or playing a wind instrument. Talk to your doctor about the type and length of your activity restrictions. Keep follow-up appointments with your doctor to monitor your healing. Pharmacologic Treatment Local Anesthetics are used for analgesia for thoracentesis and chest tube placement. Opiate analgesic agents are used for pain control, which is essential to good patient care, ensures patient comfort, and promotes pulmonary toilet. Most analgesics have sedating properties, which are beneficial for patients with painful skin lesions. These drugs are important in the initial placement of thoracostomy tubes and for controlling pain after the procedure. Benzodiazepines are used for conscious sedation. These agents are useful for premedication before pleurodesis/sclerotherapy or placement of a thoracostomy tube. Antibioti

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