Disorders of the Respiratory System PDF

Disorders of the Respiratory System AMOOBA P. A. School of Nursing and Midwifery KNUST 1 AMOOBA P. A. 5/31/2024  Learning objectives  Review of the anatomy and ph...

Disorders of the Respiratory System AMOOBA P. A. School of Nursing and Midwifery KNUST 1 AMOOBA P. A. 5/31/2024  Learning objectives  Review of the anatomy and physiology of the Resp System  Assessment of the respiratory system  Discussed with reference to definition, types, prevalence, aetiology, clinical manifestation, diagnostic investigations, differential diagnosis, and conservative/surgical management of conditions of the respiratory system  Pneumothorax, Atelectasis, Pleurisy, Pleural effusion, lung abscess, Bronchiectasis, Polyps, Emphysema, Empyema, Chest injuries, Haemothorax, fall chest 2 AMOOBA P. A. 5/31/2024  Review of Anatomy and Physiology 3 AMOOBA P. A. 5/31/2024  Review of Anatomy and Physiology 4 AMOOBA P. A. 5/31/2024  Review of Anatomy and Physiology The respiratory system is composed of the;  Upper Respiratory Tract  Lower Respiratory Tract These are responsible for ventilation - movement of air in and out the airways 5 AMOOBA P. A. 5/31/2024  Review of A&P The upper respiratory tract consist of the;  Nose – divided into external and internal portions, serves as a passageway for air to pass to the lungs, also filters impurities, humidifies and warms inhaled air  Paranasal sinuses – four pairs of bony cavities; frontal, ethmoidal, sphenoidal and maxillary. They serve as resonating chamber in speech  Pharynx (naso, oro and laryngopharynx)  Tonsils and Adenoids (lymphoid tissues)  Larynx – function in vocalization and protects lower airway from foreign substances, also facilitates cough  Trachea – serves as a passage between the larynx and bronchi. 6 AMOOBA P. A. 5/31/2024  Review of A&P The lower respiratory tract consist of the;  The Lungs – divided into lobes that contains bronchi, bronchioles and alveolar structures needed in gas exchange  Pleura – a serous membrane, consist of the parietal and visceral pleura.  Pleural space contain the pleural fluid. Fluid function as a lubricant and prevent friction during breathing  Mediasternum – middle portion of the thorax, contains the heart, thymus, aorta, vena cava and oesophagus 7 AMOOBA P. A. 5/31/2024  Function of the respiratory tract  Respiration—the exchange of oxygen and carbon dioxide between the outside atmosphere and the cells of the body  Ventilation- the mechanical process of moving air into and out of the lungs  Oxygen transport 8 AMOOBA P. A. 5/31/2024  Assessment of respiratory system 9 AMOOBA P. A. 5/31/2024  Assessment of respiratory system Health history – the nurse identifies the main reason why the patient is seeking healthcare. This should focus on physical and functional problems. Information about the precipitating factors, duration, severity and associated factors or symptoms should be collected 10 AMOOBA P. A. 5/31/2024  Assessment; Common signs and symptoms  Dyspnea – difficulty or laboured breathing  Cough  Chest pain  Sputum production  Wheezing  Clubbing of the fingers  Haemoptysis  Cyanosis 11 AMOOBA P. A. 5/31/2024  Common signs and symptoms Dyspnea  Common in many pulmonary and cardiac disorders, neurologic or neuromuscular disorders e.g myasthenia gravis, postpolio syndrome, also at the end of life of patient with varying disorders  Sudden dyspnea may indicate pneumothorax, acute respiratory obstruction, allergic reaction or myocardial infarction  Dyspnea with tachypnea associated with hypoxemia common in patients with chest trauma, shock and cardiopulmonary bypass Information about triggering factors, time and what reliefs it should be collected 12 AMOOBA P. A. 5/31/2024  Common signs and symptoms Cough  A reflex action that helps expel secretions and inhaled foreign bodies  Causes include – infection process or airborne irritants (smoke, smog, dust or gas)  Nature of cough ( dry, hacking, brassy, wheezing, loose or severe) 13 AMOOBA P. A. 5/31/2024  Common signs and symptoms Sputum production  Nature – purulent (thick and yellow, green or rust coloured) – bacterial infection  Thin mucoid – viral infection  Foul smelling and bad breath – lung abscess  Pink-tinged mucoid – lung tumour, bronchoectasis 14 AMOOBA P. A. 5/31/2024  Common signs and symptoms Chest pain  Characteristics - sharp, stabbing, intermittent, dull, aching and persistent  The pain may be located at the pathologic site or referred (neck, back or abdomen) 15 AMOOBA P. A. 5/31/2024  Common signs and symptoms  Wheezing – high pitched, musical sound heard on expiration (asthma) and inspiration (bronchitis)  Rhonchi – low pitched continuous sounds heard over the lungs in partial airway obstruction. 16 AMOOBA P. A. 5/31/2024  Common signs and symptoms; clubbing 17 AMOOBA P. A. 5/31/2024  Common signs and symptoms  Haemoptysis – expectoration of blood from the respiratory tract  Blood from lungs usually bright red, frothy and mixed with sputum  Note – vomiting blood is haematesis which is usually dark (coffee ground) 18 AMOOBA P. A. 5/31/2024  Physical examination Inspection  General appearance  Clubbing of the fingers (lung disease)  Skin – cyanosis  Nose and sinuses  Mouth and pharynx  The trachea 19 AMOOBA P. A. 5/31/2024  Inspection of the mouth and pharynx 20 AMOOBA P. A. 5/31/2024  Physical examination Thoracic inspection  Skin – colour and turgor  Chest configuration (Barrel Chest, Funnel Chest (Pectus Excavatum), Pigeon Chest (Pectus Carinatum)  Breathing patterns and respiratory rates 21 AMOOBA P. A. 5/31/2024  Chest configuration 22 AMOOBA P. A. 5/31/2024  Physical examination Thoracic Palpation  Palpate thorax for tenderness, masses, leisons and tactile fremitus ( repeat 99 or 1, 2,3 or eee, eee, eee) Thoracic Percussion  To determine whether underlying tissues are filled with air or solid material (hyperresonance or hyporesonance)  To estimate the size and locate certain organs within the thorax (diaphragm, heart, liver) 23 AMOOBA P. A. 5/31/2024  Thoracic auscultation  Assessment concludes with auscultation of the anterior, posterior and lateral thorax  Useful in assessing the flow of air through the bronchial tree and in evaluating the presence of fluid or solid obstruction in the lungs  Auscultate for normal breath sounds (vesicular, bronchovesicular and bronchial breath sounds), adventitious sounds (crackles and wheezes) and voice sounds (bronchophony and egophony) 24 AMOOBA P. A. 5/31/2024  Diagnostic Evaluation  Pulmonary function test  Arterial blood gas studies – measurement of blood ph and arterial oxygen and carbon dioxide tensions  Pulse oximetry – noninvasive continuous monitoring the oxygen saturation of haemoglobin  Cultures- throat, nasal swabs  Sputum studies  Images – chest X-ray, Computed Tomography (CT) scan, Magnetic Resonance Imaging (MRI), fluoroscopic studies, pulmonary angiography, radioisotope diagnostic procedures (Lung scans) 25 AMOOBA P. A. 5/31/2024  Diagnostic Evaluation  Pulmonary function test – include measurement of lung volumes, ventilatory function and mechanics of breathing, diffusion and gas exchange  Assess respiratory function and to determine the extend of dysfunction  Useful in monitoring course of an established respiratory diseased patient and assessing the response to therapy 26 AMOOBA P. A. 5/31/2024  Pulmonary Function Test 27 AMOOBA P. A. 5/31/2024  ENDOSCOPIC PROCEDURES  Bronchoscopy – direct inspection and examination of the larynx, trachea and bronchi through either a flexible fiberoptic bronchoscope or a rigid bronchoscope 28 AMOOBA P. A. 5/31/2024  ENDOSCOPIC PROCEDURES  Thoracoscopy – is the insertion of an endoscope, a narrow-diameter tube with a viewing mirror or camera attachment, through a very small incision (cut) in the chest wall  The purpose is to examine the lungs or other structures in the chest cavity 29 AMOOBA P. A. 5/31/2024  ENDOSCOPIC PROCEDURES  Thoracentesis - Inserting a needle through the chest wall and into the pleural space, usually to remove fluid for diagnostic or therapeutic purposes 30 AMOOBA P. A. 5/31/2024  Biopsy  Is the excision of a small amount of tissue for examination of cells Biopsy include;  Pleural biopsy  Lung biopsy  Lymph node biopsy 31 AMOOBA P. A. 5/31/2024  Assignment Write short notes on the endoscopic procedures, biopsy, thoracotomy, thoracentesis and the nurse’s interventions (responsibilities) during such procedures Format for the notes;  Definition of the procedure  Indications and contraindications  Nursing responsibilities (before, during and after the procedure)  complications 32 AMOOBA P. A. 5/31/2024  LUNG ABSCESS 33 AMOOBA P. A. 5/31/2024  Lung abscess  A localized area of destruction of lung parenchyma in which infection by pyogenic organisms results in tissue necrosis and suppuration  Lung abscess is also defined as necrosis of the pulmonary parenchyma caused by microbial infection  It manifests radiographically as a cavity with an air – fluid levels 34 AMOOBA P. A. 5/31/2024  Lung Abscess - Classification May be primary or secondary  Primary - abscess in previously healthy patient or in a patient at risk for aspiration  Secondary - associated bronchogenic neoplasm or immunocompromised patient 35 AMOOBA P. A. 5/31/2024  Lung Abscess - Classification  May also be classified as acute or chronic based upon the duration of symptoms prior to presentation for medical care  Can also be defined by responsible microbial pathogen (eg, Pseudomonas lung abscess, anaerobic bacterial lung abscess, or Aspergillus lung abscess) 36 AMOOBA P. A. 5/31/2024  Causes  Primary abscess is infectious in origin, caused by aspiration or pneumonia in the healthy host  Oral anerobes are the commonest (bacteria) 37 AMOOBA P. A. 5/31/2024  Causes  Necrotizing pneumonia Staph aureus Strep milleri / intermedius Klebsiella pneumoniae Pseudomonas aeruginosa 38 AMOOBA P. A. 5/31/2024  Risk factors Patients at the highest risk for developing lung abscess from aspiration have the following risk factors:  Dental/Periodontal disease  Paranasal sinus infection  Depressed conscious level  Impaired laryngeal closure ( cuffed endotracheal tube, tracheostomy tube, recurrent laryngeal nerve palsy )  Delayed gastric emptying/ gerd / vomiting  Seizure disorder  Alcohol abuse  Disturbances of swallowing (Dysphagia) 39 AMOOBA P. A. 5/31/2024  Risk factors  Pre-existing lung disease; Bronchiectasis Cystic fibrosis Bronchial obstruction : tumour, foreign body  Immunocompromised state  Infected pulmonary infarct  Trauma 40 AMOOBA P. A. 5/31/2024  Risk factors  Hematogenous spread from a distal site UTI Abdominal sepsis Pelvic sepsis Infective endocarditis IV drug abuse Infected IV cannulae Septic thrombophlebitis 41 AMOOBA P. A. 5/31/2024  Pathophysiology  Most often -as a complication of bacterial pneumonia or are caused by aspiration of oral anaerobes into the lungs (aspiration pneumonia)  The patients who develop lung abscess are predisposed to aspiration and commonly have periodontal disease. A bacterial reaches the lower airways, and infection is initiated because the bacteria are not cleared by the patient's host defense mechanism.  This results in aspiration pneumonitis and progression to tissue necrosis 7-14 days later, resulting in formation of lung abscess 42 AMOOBA P. A. 5/31/2024  Symptoms  The clinical effects of lung abscess include a cough that may produce bloody, purulent, or foul-smelling sputum  Pleuritic chest pain  Dyspnea  Chills; fever; headache; malaise  Night sweats  Anorexia and weight loss 43 AMOOBA P. A. 5/31/2024  Diagnostic Evaluation The following tests are used to diagnose a lung abscess:  Auscultation of the chest may reveal crackles and decreased breath sounds.  Chest X-ray  Bronchoscopy may be used to obtain cultures to identify the causative organism.  Blood cultures, Gram stain, and culture of sputum are also used to detect the causative organism.  White blood cell count commonly exceeds 10,000/ul. 44 AMOOBA P. A. 5/31/2024  Treatment for Lung Abscess  Antibiotic therapy often lasts for months until radiographic resolution or definite stability occurs. Clindamycin is often the drug of choice  Symptoms usually disappear in a few weeks  Postural drainage may facilitate discharge of necrotic material into upper airways  Oxygen therapy may relieve hypoxemia  A poor response to therapy may require resection of the lesion or removal of the diseased section of the lung  All patients need proper follow-up and serial chest X-rays 45 AMOOBA P. A. 5/31/2024  Nursing management  Note the color, quantity, quality and smell of the expectorated material including the presence of blood  Use gloves when handling articles contaminated with sputum  Provide frequent opportunities for the client to use mouthwash, brush the teeth  Encourage long term dental care  Long term antibiotics administration is usual, observe oral mucous membrane 46 AMOOBA P. A. 5/31/2024  Special Considerations and Prevention of Lung Abscess To prevent a lung abscess in the unconscious patient and the patient with seizures;  Prevent aspiration of secretions. Do this by suctioning the patient and by positioning him to promote drainage of secretions  Provide chest physiotherapy (including coughing and deep breathing)  Increase fluid intake to loosen secretions, and provide a quiet, restful atmosphere 47 AMOOBA P. A. 5/31/2024  Complications  Emphysema  Hemorrhage  Empyema  Adult respiratory distress  Bronchopleural –fistula syndrome  Pneumothorax ,  Rupture of the abscess pyoneumothorax  Inflammation of the  Fibrosis, bronchiectasis, membrane surrounding the amyloidosis heart,  Spread of the abscess to  Chronic inflammation of other parts of the lung the lung 48 AMOOBA P. A. 5/31/2024  ATELECTASIS (Collapse) 49 AMOOBA P. A. 5/31/2024  Atelectasis  Atelectasis is the collapse of part or (much less commonly) all of a lung.  An abnormal condition characterized by the collapse of lung tissue, preventing the respiratory exchange of carbon dioxide and oxygen 50 AMOOBA P. A. 5/31/2024  Description of atelectasis  Atelectasis can result from an obstruction (blockage) of the airways that affects tiny air sacs called alveoli  Alveoli are very thin-walled and contain a rich blood supply. They are important for lung function, since their purpose is the exchange of oxygen and carbon dioxide  When the airways are blocked by a mucous "plug," foreign object, or tumor, the alveoli are unable to fill with air and collapse of lung tissue can occur in the affected area 51 AMOOBA P. A. 5/31/2024  Description of atelectasis  Atelectasis is a potential complication following surgery, especially in individuals who have undergone chest or abdominal operations resulting in associated abdominal or chest pain during breathing  Congenital atelectasis can result from a failure of the lungs to expand at birth. This congenital condition may be localized or may affect all of both lungs 52 AMOOBA P. A. 5/31/2024  Types of Atelectasis 1. Resorption atelectasis. 2. Compression atelectasis. 3. Contraction atelectasis. 53 AMOOBA P. A. 5/31/2024  Types of Atelectasis Resorption atelectasis - Result from complete obstruction of an airway and absorption of entrapped air. Obstruction can be caused by: a. Mucous plug ( postoperatively or exudates within small bronchi seen in bronchial asthma and chronic bronchitis). b. Aspiration of foreign body. c. Neoplasm. d. enlarged lymph node - The involvement of lung depend on the level of airway obstruction. - Lung volume is diminished and the mediastinum may shift toward the atelectatic lung. 54 AMOOBA P. A. 5/31/2024  2. Compression atelectasis Results whenever the pleural cavity is partially or completely filled by fluid, blood, tumor or air, e.g. - cardiac failure - neoplastic effusion - abnormal elevation of diaphragm in peritonitis or subdiaphragmatic abscess. 55 AMOOBA P. A. 5/31/2024  3. Contraction atelectasis  Local or generalized fibrotic changes in pleura or lung preventing full expansion of the lung 56 AMOOBA P. A. 5/31/2024  Causes  Atelectasis is caused by a blockage of the air passages (bronchus or bronchioles) or by pressure on the outside of the lung  It is common after surgery especially upper abdominal or thoracic procedures  Also associated with bedridden clients and with a history of smoking. 57 AMOOBA P. A. 5/31/2024  Risk factors  Inhalation Anesthesia  Smoke inhalation  Aspiration of gastric content  Foreign object in the airway (most common in children)  Lung diseases  Mucus that plugs the airway  Pressure on the lung caused by a buildup of fluid between the ribs and the lungs (called a pleural effusion)  Prolonged bed rest with few changes in position  Shallow breathing (may be caused by painful breathing)  Tumors that block an airway 58 AMOOBA P. A. 5/31/2024  Clinical Manifestations  Breathing difficulty  Chest pain  Cough  Hypoxemia  Tachypnea  Tachycardia  Cyanosis 59 AMOOBA P. A. 5/31/2024  Diagnostic evaluation  Bronchoscopy to rule out an obstructing neoplasm or a foreign body if the cause is unknown  Chest CT scan  Chest x-ray may show a shadow in the area of collapse  Chest auscultation may reveal bronchial or diminished breathe sounds and crackles over the involved area 60 AMOOBA P. A. 5/31/2024  Management  The goal of treatment is to re-expand the collapsed lung tissue. If fluid is putting pressure on the lung, removing the fluid may allow the lung to expand. The following are treatments for atelectasis:  Clap (percussion) on the chest to loosen mucus plugs in the airway  Perform deep breathing exercises (with the help of incentive spirometry devices)  Remove or relieve any blockage by bronchoscopy, coughing or suctioning  If a tumor is the cause of atelectasis, surgery may be necessary to remove it 61 AMOOBA P. A. 5/31/2024  Management  Tilt the person so the head is lower than the chest (called postural drainage). This allows mucus to drain more easily.  Turn the person to lie on the healthy side, allowing the collapsed area of lung to re-expand  Use aerosolized respiratory treatments (inhaled medications) to open the airway  Antibiotics are commonly used to fight the infection that often accompanies atelectasis 62 AMOOBA P. A. 5/31/2024  Expectations (prognosis)  In an adult, atelectasis in a small area of the lung is usually not life threatening. The rest of the lung can make up for the collapsed area, bringing in enough oxygen for the body to function  Large areas of atelectases may be life threatening, especially in a baby or small child, or someone who has another lung disease or illness  The collapsed lung usually reinflates slowly if the blockage of the airway has been removed. However, some scarring or damage may remain 63 AMOOBA P. A. 5/31/2024  Prevention  Encourage movement and deep breathing in anyone who is bedridden for long periods  Keep small objects out of the reach of young children  Maintain deep breathing after anesthesia 64 AMOOBA P. A. 5/31/2024  Complications  Pneumonia may develop quickly after atelectasis in the affected part of the lung 65 AMOOBA P. A. 5/31/2024  PLEURAL CONDITIONS 66 AMOOBA P. A. 5/31/2024  PLEURAL CONDITIONS Disorders of the pleura include  Pleurisy - inflammation of the pleura that causes sharp pain with breathing  Pleural effusion - excess fluid in the pleural space  Pneumothorax - buildup of air or gas in the pleural space  Hemothorax - buildup of blood in the pleural space 67 AMOOBA P. A. 5/31/2024  PLEURISY  Pleurisy is inflammation of the lining of the lungs and chest (the pleura) that leads to chest pain (usually sharp) when you take a breath or cough 68 AMOOBA P. A. 5/31/2024 69 AMOOBA P. A. 5/31/2024 70 AMOOBA P. A. 5/31/2024  Pleurisy - classification  Dry pleurisy (pleuritis sicca)  Pleurisy with effusion (pleuritis exudativa) The character of the inflammatory effusion may be different: serous, serofibrinous, purulent, and haemorrhagic 71 AMOOBA P. A. 5/31/2024  Causes  Pleurisy may develop from lung inflammation due to infections such as pneumonia or tuberculosis. It is often a sign of a viral infection of the lungs. This inflammation also causes the sharp chest pain of pleurisy  It may also occur with:  Asbestos-related disease  Certain cancers  Chest trauma  Pulmonary embolus  Rheumatic diseases 72 AMOOBA P. A. 5/31/2024  Pathophysiology  Pleurisy, most often develop in conjunction with tuberculosis, pneumonia, upper respiratory tract infection, injury to chest or infection by microbes (pneumococci, streptococci, staphylococci) and after thoracotomy  The parietal pleura has nerve endings and the visceral parietal has not  When the inflamed pleural membranes rub together during respiration (intensified on inspiration), the result is severe, sharp, knifelike pain 73 AMOOBA P. A. 5/31/2024  Clinical Manifestations  The main symptom of pleurisy is pain in the chest. This pain most likely occurs when you take a deep breath in or out, or cough. Some people feel the pain in the shoulder.  Deep breathing, coughing, and chest movement makes the pain worse.  Pleurisy can cause fluid to collect inside the chest cavity. This can make breathing difficult and may cause the following symptoms:  Bluish skin color (cyanosis)  Coughing  Shortness of breath  Rapid breathing (tachypnea) 74 AMOOBA P. A. 5/31/2024  Diagnostic evaluation  When you have pleurisy, the normally smooth lining of the lung (the pleura) become rough. They rub together with each breath, and may produce a rough, grating sound called a "friction rub." This can be heard by auscultation The following tests can be performed:  Full blood count  Thoracentesis  Ultrasound of the chest  Chest X-ray 75 AMOOBA P. A. 5/31/2024  Medical Management  Remove fluid in the lungs by thoracentesis and check it for signs of infection.  Treatment depends on what is causing the pleurisy. Bacterial infections are treated with antibiotics. Some bacterial infections require a surgical procedure to drain all the infected fluid.  Viral infections normally run their course without medications.  Patients often can control the pain of pleurisy with acetaminophen or anti-inflammatory drugs such as ibuprofen 76 AMOOBA P. A. 5/31/2024  Nursing Management  Enhance comfort by splinting the chest wall. This achieved by frequently turning the patient to the affected side, this reduces the stretching of the pleurae  Teach the patient use the hands or a pillow to splint the rib cage while coughing 77 AMOOBA P. A. 5/31/2024  Complications  Breathing difficulty  Collapsed lung due to thoracentesis  Complications from the original illness 78 AMOOBA P. A. 5/31/2024  PLEURAL EFFUSION 79 AMOOBA P. A. 5/31/2024  PLEURAL EFFUSION  It is the abnormal accumulation of fluid in the pleural space resulting from excess fluid production or decreased absorption  Normally, the pleural space approximately contains 5- 10mL of fluid 80 AMOOBA P. A. 5/31/2024  Types Of Effusions  Transudative Pleural Effusions  Exudative Effusions 81 AMOOBA P. A. 5/31/2024  Transudative Pleural Effusions  A fluid substance that has passed through a membrane or has been extruded from a tissue  It is of high fluidity and has a low content of protein, cells, or solid materials derived from cells  It caused by fluid leaking into the pleural space. This is caused by increased pressure in, or low protein content in, the blood vessels.  A transudate is a clear fluid, similar to blood serum  It reflect a systemic disturbance of body 82 AMOOBA P. A. 5/31/2024  Causes of Transudates  Atelectasis  (early)Cirrhosis  Congestive heart failure  Hypoalbuminemia  Nephrotic syndrome  Peritoneal dialysis  End-stage renal disease 83 AMOOBA P. A. 5/31/2024  Exudative Effusions  A fluid rich in protein and cellular elements that oozes out of blood vessels due to inflammation  It is caused by blocked blood vessels, inflammation, lung injury, and drug reactions  An exudate—which often is a cloudy fluid, containing cells and much protein  Signify underlying local (pleuropulmonary) disease. 84 AMOOBA P. A. 5/31/2024  Causes of Exudates  Asbestos exposure  Atelectasis  Hemothorax Infection (bacteria, viruses, fungi, tuberculosis, or parasites)  Pulmonary embolism  Uremia 85 AMOOBA P. A. 5/31/2024  Types of fluids Four types of fluids can accumulate in the pleural space:  Serous fluid (hydrothorax): A hydrothorax is a condition that results from serous fluid accumulating in the pleural cavity. This specific condition can be related to cirrhosis with ascites in which ascitic fluid leaks into the pleural cavity  Blood (haemothorax): is a condition that results from blood accumulating in the pleural cavity 86 AMOOBA P. A. 5/31/2024  Types of fluids  Chyle (chylothorax): chyle is a milky bodily fluid consisting of lymph and emulsified fats, or free fatty acids (FFAs). It is formed in the small intestine during digestion of fatty foods. - is a type of pleural effusion. It results from lymphatic fluid (chyle) accumulating in the pleural cavity  Pus (pyothorax or empyema): is an accumulation of pus in the pleural cavity 87 AMOOBA P. A. 5/31/2024  Pathophysiology  It is explained by increased pleural fluid formation or decreased pleural fluid absorption  Increased pleural fluid formation can result from elevation of hydrostatic pressure and decreased osmotic pressure  It leads to increased capillary permeability and passage of fluid is through openings in the diaphragm  Hence production increases and absorption decreases due to lymphatic obstruction  Pleural effusions produce a restrictive ventilatory defect and also decrease the total lung capacity and vital capacity 88 AMOOBA P. A. 5/31/2024  Symptoms  Chest pain, usually a sharp pain that is worse with cough or deep breaths  Cough  Fever  Hiccups  Rapid breathing  Shortness of breath  Sometimes there are no symptoms 89 AMOOBA P. A. 5/31/2024  Diagnostic evaluation  listen to breath sounds with a stethoscope and tap the chest to listen for dullness. The following tests may help to confirm a diagnosis:  Chest CT scan  Chest x-ray  Pleural fluid analysis (examining the fluid under a microscope to look for bacteria, amount of protein, and presence of cancer cells)  Thoracentesis (a sample of fluid is removed with a needle inserted between the ribs)  Thoracic CT  Ultrasound of the chest 90 AMOOBA P. A. 5/31/2024  Medical Management Treatment aims to:  Remove the fluid  Prevent fluid from building up again  Treating the cause of the fluid buildup  Therapeutic thoracentesis may be done if the fluid collection is large and causing chest pressure, shortness of breath, or other breathing problems, such as low oxygen levels  Removing the fluid allows the lung to expand, making breathing easier. 91 AMOOBA P. A. 5/31/2024  Medical Management Treating the cause of the effusion  For example, pleural effusions caused by congestive heart failure are treated with diuretics and other medications that treat heart failure.  Pleural effusions caused by infection are treated with appropriate antibiotics.  In people with cancer or infections, the effusion is often treated by using a chest tube for several days to drain the fluid. 92 AMOOBA P. A. 5/31/2024  Medical Management  Sometimes, small tubes can be left in the pleural cavity for a long time to drain the fluid. In some cases, the following may be done:  Chemotherapy  Putting medication into the chest that prevents fluid from building up again after it is drained  Radiation therapy  Surgery 93 AMOOBA P. A. 5/31/2024  Nursing Management  Prepares and position the patient for thoracentesis and offer support throughout the procedure  Record the amount of thoracentesis fluid and sent it for the appropriate laboratory testing  Monitoring chest tube drainage and water-seal system if they are used  Help patient to assume position that facilitate adequate spread of talc when it is instilled  Help patient to assume positions that are least painful 94 AMOOBA P. A. 5/31/2024  Complications  A lung that is surrounded by excess fluid for a long time may be damaged.  Pleural fluid that becomes infected may turn into an abscess, called an empyema, which will need to be drained with a chest tube.  Pneumothorax (air in the chest cavity) can be a complication of the thoracentesis procedure. 95 AMOOBA P. A. 5/31/2024  Assignment  Write short notes on chest tube drainage and water-seal system  Discuss the nurse’s responsibilities before, during and after these procedures 96 AMOOBA P. A. 5/31/2024  EMPYEMA 97 AMOOBA P. A. 5/31/2024  EMPYEMA  Is the collection of pus in the space between the lung and the inside of the chest wall (pleural space)  Empyema in the pleural cavity is sometimes called empyema thoracis, or empyema of the chest  Empyema itself is not disease it is actually a condition complicated by another disease 98 AMOOBA P. A. 5/31/2024  Stages of Empyema Stage I - “Exudative”  Sterile pleural fluid develops secondary to inflammation without fusion of the pleura; swelling of pleural membranes Stage II - “Fibrinopurulent”  A fibrinous peel develops on both pleural surfaces limiting lung expansion due to heavy fibrin deposits Stage III - “Organizing”  In-growth of capillaries and fibroblasts into the fibrinous peel and deposition of collagen 99 AMOOBA P. A. 5/31/2024  Causes  A number of different organisms, including bacteria, fungi, and amoebas, in connection with pneumonia  Common cause is pulmonary infection as a result of aerobic bacteria such as Streptococcus pneumonia, Staphylococcus aureus, E. coli, Klebsiella pneumoniae, Haemophilus influenzae.  Other causes include: Chest trauma(blunt chest wound, chest surgery, lung abscess, or a ruptured esophagus)  Septicaemia (very rare blood borne infection)  Subdiaphragmatic causes as liver abscess 100 AMOOBA P. A. 5/31/2024  Risk factors  Bacterial pneumonia  Lung abscess  Thoracic surgery  Trauma or injury to the chest  In rare cases, empyema can occur when a needle is inserted through the chest wall to draw off fluid in the pleural space (thoracentesis) 101 AMOOBA P. A. 5/31/2024  Clinical Manifestations  Chest pain, which worsens when you breathe in deeply (inspiration)  Dry cough  Excessive sweating, especially night sweats  Fever and chills  General discomfort, uneasiness, or ill feeling (malaise)  Shortness of breath  Unintentional weight loss 102 AMOOBA P. A. 5/31/2024  Diagnostic evaluation  Decreased breath sounds or a friction rub on auscultation Tests may include the following:  Chest x-ray- empyema appears as a cloudy or opaque area  CT scan of chest  Pleural fluid gram stain and culture  Thoracentesis 103 AMOOBA P. A. 5/31/2024  Medical Management  The goal of treatment is to cure the infection and remove the collection of pus from the lung  Antibiotics are prescribed to control the infection (penicillin and vancomycin, Ceftriaxone/Cefotaxime plus Clindomycin)  Needle aspiration (thoracentesis), if fluid volume is small and not too purulent or too thick  Chest tube insertion (tube thoracotomy) attach to water-seal drainage to completely drain the pus  A surgeon may need to perform a procedure (Thoracotomy) to peel away the lining of the lung (decortication) if the lung does not expand properly. 104 AMOOBA P. A. 5/31/2024  Needle aspiration 105 AMOOBA P. A. 5/31/2024  Medical Management Thoracostomy  Open drainage with pleural peel decortication  Excision of the thick fibrous pleural rind and removal of infectious material  Longer and complicated procedure  Reserved for late presenting empyema with significant fibrous pleural rind, complex empyema and chronic empyema 106 AMOOBA P. A. 5/31/2024  Nursing Management  Help patient to cope with the condition and instructs patient in lung-expanding breathing exercise to restore normal respiratory function  Provide specific care to the method of drainage of the pleural fluid (needle aspiration, closed chest drainage) 107 AMOOBA P. A. 5/31/2024  Expectations (prognosis)  When empyema complicates pneumonia, the risk of permanent lung damage and death goes up. Patients will need long-term treatment with antibiotics and drainage. However, most people fully recover from empyema 108 AMOOBA P. A. 5/31/2024  Complications  Pleural thickening  Reduced lung function 109 AMOOBA P. A. 5/31/2024  CHEST TRAUMA 110 AMOOBA P. A. 5/31/2024  Chest Trauma  Chest trauma results in multiple chest injuries  Is life threatening because chest injuries involves organs in the thoracic cage  Trauma is leading cause of death hospitalization, short and long-term disability for all ages from first –forty years.  25% of all trauma death due to chest injuries 111 AMOOBA P. A. 5/31/2024  Classifications of Chest Injuries  Skeletal injury  Pulmonary injury  Heart and great vessel injury  Diaphragmatic injury 112 AMOOBA P. A. 5/31/2024  Classification; Mechanism of Injury  Blunt Trauma- Blunt force to chest (motor vehicle crashing, falls, bicycle crashing, moving object hitting the chest)  Penetrating Trauma- Projectile that enters chest causing small or large hole (gunshot, stabbing)  Compression Injury- Chest is caught between two objects and chest is compressed (direct blow to the chest) 113 AMOOBA P. A. 5/31/2024  Types of Chest Injuries; blunt trauma  Thoracic cage fractures (Rib Fractures)  Lung contusion and tears (simple/closed Pneumothorax, Tension pneumothorax)  Myocardium contusion  Aortic rupture  Pulmonary Contusion 114 AMOOBA P. A. 5/31/2024  Penetrating Trauma 115 AMOOBA P. A. 5/31/2024  Types of Penetrating Chest Injuries  Open pneumothorax  Aortic Tears  Vena Cava Tears  Diaphragmatic Rupture 116 AMOOBA P. A. 5/31/2024  Signs and Symptoms of Chest Trauma  Chest Wall Bruising  Rapid, Weak Pulse  Chest Pain  Hypotension  Dyspnea  Trachea Deviation  Cough  Distended Neck Veins  Asymmetrical Chest Wall  Bloodshot or Bulging Eyes Movement  Cyanosis 117 AMOOBA P. A. 5/31/2024  Diagnostic evaluation  Chest X-ray  Chest computed tomography  Arteriography 118 AMOOBA P. A. 5/31/2024  Emergency Medical Treatment for Chest Trauma  Patent Airway  Assess S/S of Respiratory Distress  Administer O2 and Continuous O2 saturation monitoring  Check Vital Signs and Assess for shock  IV access x 2  Check for Bleeding, Hct & Hgb  Remove clothes, Assess for other injuries  Seal open chest wound with a 3 sided air occlusive dressing  Do not remove impaled object(s) 119 AMOOBA P. A. 5/31/2024  Haemothorax 120 AMOOBA P. A. 5/31/2024  Haemothorax  Hemothorax is a collection of blood in the space between the chest wall and the lung (the pleural cavity).  Usually occurs due to lacerated blood vessel in thorax 121 AMOOBA P. A. 5/31/2024  Haemothorax 122 AMOOBA P. A. 5/31/2024  Haemothorax 123 AMOOBA P. A. 5/31/2024  Haemothorax May put pressure on the heart AMOOBA P. A. 124 5/31/2024  Causes  The most common cause of hemothorax is chest trauma It can also occur in patients who have:  A defect of blood clotting  Death of lung tissue (pulmonary infarction)  Lung or pleural cancer  Placement of a central venous catheter  Thoracic or heart surgery  Tuberculosis 125 AMOOBA P. A. 5/31/2024  Haemothorax Where does the blood come from. 126 AMOOBA P. A. Lots of blood vessels 5/31/2024  Symptoms  Chest pain  Diminished Breath Sounds  Low blood pressure on Affected Side  Pale, cool and clammy skin  Tachycardia  Rapid heart rate  Flat Neck Veins  Rapid, shallow breathing  Shortness of breath  Restlessness  Frothy, Bloody Sputum  Anxiety 127 AMOOBA P. A. 5/31/2024  Diagnostic evaluation  Decreased or absent breath sounds on the affected side. Signs of hemothorax may be seen on the following tests:  Chest x-ray  CT scan  Pleural fluid analysis  Thoracentesis 128 AMOOBA P. A. 5/31/2024  Management  The goal of treatment is to get the patient stable, stop the bleeding, and remove the blood and air in the pleural space. A chest tube is inserted through the chest wall to drain the blood and air. It is left in place for several days to re-expand the lung.  When a hemothorax is severe and a chest tube alone does not control the bleeding, surgery (thoracotomy) may be needed to stop the bleeding.  The cause of the hemothorax should be also treated. In people who have had an injury, chest tube drainage is often all that is needed. Surgery is often not needed 129 AMOOBA P. A. 5/31/2024  Complications  Collapsed lung, leading to respiratory failure  Death  Empyema  Fibrosis or scarring of the pleural membranes  Pneumothorax  Shock 130 AMOOBA P. A. 5/31/2024  PNEUMOTHORAX 131 AMOOBA P. A. 5/31/2024  PNEUMOTHORAX  Pneumothorax is the collection of air in the space(pleural space) around the lungs  This buildup of air puts pressure on the lung, so it cannot expand as much as it normally does when you take a breath 132 AMOOBA P. A. 5/31/2024  Types of pneumothorax  Simple/close Pneumothorax  Open Pneumothorax  Tension Pneumothorax 133 AMOOBA P. A. 5/31/2024 Simple/Closed Pneumothorax  Opening in lung tissue that leaks air into chest cavity  Blunt trauma is main cause  May be spontaneous  Usually self correcting 5/31/2024 AMOOBA P. A. 134  S/S of Simple/Closed Pneumothorax  Chest Pain  Dyspnea  Tachypnea  Decreased Breath Sounds on Affected Side 135 AMOOBA P. A. 5/31/2024 Open Pneumothorax  Opening in chest cavity that allows air to enter pleural cavity  Causes the lung to collapse due to increased pressure in pleural cavity  Can be life threatening and can deteriorate rapidly 5/31/2024 AMOOBA P. A. 136  Open Pneumothorax 137 AMOOBA P. A. 5/31/2024  Open Pneumothorax Inhale 138 AMOOBA P. A. 5/31/2024  Open Pneumothorax Exhale 139 AMOOBA P. A. 5/31/2024  Open Pneumothoarx Inhale 140 AMOOBA P. A. 5/31/2024  S/S of Open Pneumothorax  Dyspnea  Sudden sharp pain  Subcutaneous Emphysema  Decreased lung sounds on affected side  Red Bubbles on Exhalation from wound (Sucking chest wound) 141 AMOOBA P. A. 5/31/2024  Tension Pneumothorax  Air builds in pleural space with no where for the air to escape  Results in collapse of lung on affected side that results in pressure on mediastium,the other lung, and great vessels 142 AMOOBA P. A. 5/31/2024  Tension Pneumothorax Each time we inhale, the lung collapses further. There is no place for the air to escape.. 143 AMOOBA P. A. 5/31/2024  Tension Pneumothorax The trachea is pushed to the good side Heart is being compressed 144 AMOOBA P. A. 5/31/2024  S/S of Tension Pneumothorax  Severe Dyspnea  Accessory Muscle Use  Absent Breath sounds on  Narrowing Pulse Pressures affected side  Hypotension  Tachypnea  Anxiety/Restlessness  Tachycardia  Tracheal Deviation  Poor Color (late if seen at all) 145 AMOOBA P. A. 5/31/2024  Diagnostic evaluation  There are decreased or no breath sounds on the affected side when heard through a stethoscope. Tests include:  Chest x-ray to tell whether there is air outside the lung  Arterial blood gases 146 AMOOBA P. A. 5/31/2024  Medical Management  A small pneumothorax may go away on its own.You may only need oxygen and rest.  A needle may be use to pull the extra air out from around the lung so it can expand more fully  If it is a large pneumothorax, a chest tube will be placed between the ribs into the space around the lungs to help drain the air and allows the lung to re-expand.  The chest tube can be left in place for several days 147 AMOOBA P. A. 5/31/2024  Medical management  Some patients with a collapsed lung need extra oxygen, which helps the air around the lung be reabsorbed more quickly  Lung surgery may be needed to treat pneumothorax or to prevent future episodes  The area where the leak occurred may be repaired  Sometimes, a special chemical is placed into the area of the collapsed lung. This chemical causes a scar to form 148 AMOOBA P. A. 5/31/2024 Needle Decompression 5/31/2024 AMOOBA P. A. 149  Complications  Another collapsed lung in the future  Shock 150 AMOOBA P. A. 5/31/2024  FLAIL CHEST 151 AMOOBA P. A. 5/31/2024  Flail Chest The breaking of 2 or more ribs in 2 or more places 152 AMOOBA P. A. 5/31/2024 Flail Chest 5/31/2024 AMOOBA P. A. 153  S/S of Flail Chest  Shortness of Breath  Paradoxical Movement of the chest  Bruising/Swelling  Crepitus( Grinding of bone ends on palpation) 154 AMOOBA P. A. 5/31/2024  Management of Flail Chest  ABC’s with cervical spine control  Monitor Patient for signs of Pneumothorax or Tension Pneumothorax  Use Gloved hand as splint till bulky dressing can be put on patient  Advance Life Support as soon as possible 155 AMOOBA P. A. 5/31/2024 Bulky Dressing for splint of Flail Chest  Use Trauma bandage and Triangular Bandages to splint ribs.  Can also place a bag of D5W on area and tape down. 5/31/2024 AMOOBA P. A. 156  Basic Life Support Plus Care  Monitor Cardiac Rhythm  Establish IV access  Airway management to include Intubation  Observe for patient to develop Pneumothorax and even worse Tension Pneumothorax  If tension develops needle decompress affected side  Rapid Transport! Remember a True Emergency 157 AMOOBA P. A. 5/31/2024  BRONCHIECTASIS 158 AMOOBA P. A. 5/31/2024  Bronchiectasis  Chronic necrotizing infection of the bronchi and bronchioles leading to or associated with abnormal dilatation of these airways.  Bronchiectasis is destruction and widening of the large airways.  Bronchial dilatation should be permanent  If the condition is present at birth, it is called congenital bronchiectasis  If it develops later in life, it is called acquired bronchiectasis 159 AMOOBA P. A. 5/31/2024  Conditions associated with Bronchiectasis 1. Bronchial obstruction Localized: - tumor, foreign bodies or mucous impaction Generalized: - bronchial asthma - chronic bronchitis 160 AMOOBA P. A. 5/31/2024  Conditions associated with Bronchiectasis 2. Congenital or hereditary conditions: - Congenital bronchiactasis - Cystic fibrosis. - Intralobar sequestration of the lung. - Immunodeficiency status. - Immotile cilia and kartagner syndrome. 3. Necrotizing pneumonia Caused by TB, staphylococci or mixed infection. 161 AMOOBA P. A. 5/31/2024  Causes  Recurrent inflammation or infection of the airways  It most often begins in childhood as a complication from infection or inhaling a foreign object  Cystic fibrosis causes about a third of all bronchiectasis cases in the United States  Certain genetic conditions can also cause bronchiectasis, including primary ciliary dyskinesia and immunodeficiency syndromes.  The condition can also be caused by routinely breathing in food particles while eating 162 AMOOBA P. A. 5/31/2024  Symptoms  Symptoms often develop  Clubbing of fingers gradually, and may occur  Coughing up blood months or years after the  Cough that gets worse event that causes the when lying on one side bronchiectasis  Fatigue They may include:  Paleness  Bluish skin color  Shortness of breath that  Breath odor gets worse with exercise  Chronic cough with large  Weight loss amounts of foul-smelling sputum  Wheezing 163 AMOOBA P. A. 5/31/2024  Diagnostic evaluation  listening to the chest with a stethoscope, you may hear small clicking, bubbling, wheezing, rattling, or other sounds, usually in the lower lobes of the lungs Tests may include:  Aspergillosis precipitin test (to check for signs of the aspergillosis fungus)  Chest x-ray  Chest CT  Sputum culture  Complete blood count (CBC)  Genetic testing, including sweat test for cystic fibrosis  Serum immunoglobulin electrophoresis 164 AMOOBA P. A. 5/31/2024  Treatment  Treatment is aimed at controlling infections and bronchial secretions, relieving airway obstruction, and preventing complications.  Regular, daily drainage to remove bronchial secretions is a routine part of treatment. A respiratory therapist can show the patient coughing exercises that will help.  Antibiotics, bronchodilators, and expectorants are often prescribed for infections.  Surgery to resect the lung may be needed if medicine does not work or if the patient has massive bleeding 165 AMOOBA P. A. 5/31/2024  Prevention  The risk may be reduced if lung infections are promptly treated.  Childhood vaccinations and a yearly flu vaccine help reduce the chance of some infections. Avoiding upper respiratory infections, smoking, and pollution may also reduce your risk of infection. 166 AMOOBA P. A. 5/31/2024  Complications  Cor pulmonale  Coughing up blood  Low oxygen levels (in severe cases)  Recurrent pneumonia 167 AMOOBA P. A. 5/31/2024  Thank you 168 AMOOBA P. A. 5/31/2024