COMMON RESPIRATORY DISORDERS

Part 2
PNEUMONIA (PNA)
An acute infection of the pulmonary parenchyma that is associated with either an acute infiltration on chest x-
ray or by auscultation of breath sounds that are consistent with pneumonia

Types of Pneumonia
Hospital-acquired pneumonia (HAP)
🢝 PNA more than 48 hours after admission to a hospital

Ventilator-associated pneumonia (VAP)

🢝 PNA more than 48 to 72 hours after intubation

Health care–associated pneumonia (HCAP)

🢝 The patient is hospitalized for more than 2 days within the past 90 days

🢝 Nursing home or long-term care resident

🢝 Chemotherapy, or wound care in the past 30 days

🢝 Received treatment in a hospital or hemodialysis clinic 43
 type of
ETIOLOGY
Bacteria, viruses, mycoplasmas, fungi, and foreign material
Streptococcus pneumoniae (pneumococcus) is the predominant pathogen associated
with community-acquired pneumonia (CAP).
Typical pneumonia
🢝 S. pneumoniae, S. pyrogenes, and S. aureus
🢝 Bacteria multiply in the alveoli, causing inflammation and accumulation of fluid within
the alveoli.
Atypical pneumonia
🢝 Mycoplasma pneumoniae, C. pneumoniae, influenza virus, adenovirus, and Legionella
species
🢝Inflammatory changes in the alveolar septa and lung interstitium.

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 PATHOPHYSIOLOGY

▪Inflammatory response to inhaled or aspirated foreign material or the

uncontrolled multiplication of microorganisms invading the lower respiratory tract.

▪Accumulation of neutrophils and other pro-inflammatory cytokines in the

peripheral bronchi and alveolar spaces.

▪Normal pulmonary defense mechanisms are either impaired or overwhelmed,

allowing microorganisms to multiply rapidly.

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 ASSESSMENT
➢ History, Risk factors, S & S ➢ Diagnostic Studies
▪Chest radiograph (AP and lateral)
➢ Physical findings
▪Blood cultures
🢝 Hypoxemia, dyspnea, new onset respiratory ▪CBC
symptoms, fever, and chills ▪Electrolytes
▪Renal and liver function
🢝 Dullness with percussion, decreased breath
▪ABG
sounds, crackles or bronchial breath sounds
▪Thoracentesis
🢝 Myalgia, GI symptoms, confusion in elderly ▪Sputum
patients
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MANAGEMENT
Antibiotic therapy:
🢝 Cornerstone of treatment.
🢝 First dose within 8 hours of arrival to hospital.
Supportive therapy:
🢝 Oxygen, mechanical ventilation, pulmonary drainage, nutritional
support.
Prevention:
🢝 Influenza and pneumococcal vaccine.

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 PNEUMONIA SUMMARY
Signs and Symptoms Fever, chills
Chest pain
Dyspnea
Productive
cough
Crackles and wheezes
Diagnostic Tests Chest x-ray
Sputum cultures
Therapeutic Antibiotics
Measures Supplemental
oxygen
Bronchodilators, expectorants
Rest, fluids
Complications Pleurisy, pleural effusion
Atelectasis
Priority Nursing Impaired Gas Exchange
Diagnoses Ineffective Airway Clearance
RESPIRATORY FAILURE
 ACUTE RESPIRATORY FAILURE
Pathophysiology
▪Acute respiratory failure is diagnosed when the patient is unable to maintain
adequate blood gas values.

▪Hypoxemia may result from inadequate ventilation (air movement in and out of lungs)
or poor oxygenation (adequate ventilation but the inability to get the oxygen into the
blood and therefore the cells) or both.

▪Hypercapnia and respiratory acidosis occur when the diseased lungs are unable to
effectively eliminate carbon dioxide.
 ACUTE RESPIRATORY FAILURE

Etiology
➢ An acute respiratory infection in a patient with chronic obstructive disease
is
often the precipitating factor in acute respiratory failure.

➢Other causes include central nervous system (CNS) disorders that affect the
muscles of breathing, such as a stroke, spinal cord injury, or myasthenia
gravis; inhalation of toxic substances; opioid overdose; and aspiration.
 ACUTE RESPIRATORY FAILURE
Prevention
▪ Avoidance of respiratory infections in patients with chronic respiratory disease is important.

▪Instruct patients to notify their HCP immediately if sputum becomes purulent so treatment can be
initiated.
▪ Sedatives and narcotics should be used carefully or avoided in patients with chronic respiratory
disease because these are respiratory depressants and can precipitate failure.

▪Careful monitoring and early intervention are essential in patients at risk for respiratory failure.
 ACUTE RESPIRATORY FAILURE

Signs and Symptoms

▪The patient with impending respiratory failure may become restless, confused, agitated, or
sleepy.

▪Arterial blood gases show decreasing PaO2 and pH and increasing PaCO2, which lead to
respiratory acidosis.

▪The patient is cyanotic and dyspneic, and respirations becomes rapid and deep in an effort
to blow off excess CO2.
 ACUTE RESPIRATORY FAILURE

Diagnostic Tests
➢ ABG: Respiratory failure is diagnosed when PaO2 falls below 60 mm Hg or PaCO2 is
elevated above 50 mm Hg.
➢ Sputum cultures
➢ Chest x-ray
➢ Pulse oximetry is used to continuously monitor oxygen saturation.
➢ Patients cared for in ICUs may have additional monitoring, including capnography
 THERAPEUTIC MEASURES
▪Oxygen therapy via nasal cannula or mask is provided. High-flow oxygen may be necessary
to oxygenate the patient, but if the patient has a chronically high PaCO2, the high flow can
interfere with the hypoxic drive.
▪(Remember the rule “Never give a chronic CO2 retainer more than 2 liters of
oxygen”?
-- If a flow rate greater than 1 to 2 L/min is necessary, mechanical ventilation via an
endotracheal tube may be required.
▪ Antibiotics
▪ Bronchodilators promote ventilation and secretion removal.
▪ Suctioning is indicated if the patient is unable to cough effectively.
ACUTE RESPIRATORY DISTRESS
SYNDROME/
ACUTE LUNG INJURY
ACUTE RESPIRATORY DISTRESS
SYNDROME/ ACUTE LUNG INJURY
Acute respiratory distress syndrome (ARDS) is a group of disorders that has
diverse causes but similar pathophysiology, symptoms, and treatment.
Pathophysiology and Etiology
ARDS occurs because of acute lung injury (ALI).
The most common cause of injury is widespread sepsis.
Other causes include pneumonia, trauma, shock, narcotics overdose, inhalation of irritants,
burns, pancreatitis, and aspiration.
ACUTE RESPIRATORY DISTRESS
SYNDROME/ ACUTE LUNG INJURY
ARDS usually affects patients without a previous history of lung
disease.
Tired respiratory muscles, in combination with edema and
atelectasis, reduce gas exchange and result in hypoxia.
As the condition progresses, atelectasis and edema worsen
and the lungs may hemorrhage.
A chest x-ray examination appears white because of the excessive fluid
in the lungs. These changes explain some of the older names for what
is now known as ARDS: wet lung, white lung, shock lung, and stiff
lung.
 ACUTE RESPIRATORY DISTRESS
SYNDROME/ ACUTE LUNG INJURY
Prevention:-
Early recognition and treatment of underlying disorders is important in
prevention of ARDS.
Good nursing care can help reduce aspiration and some types
of pneumonia.
Signs and Symptoms
1. The patient presents with dyspnea, tachypnea, and cyanosis.
2. Initial respiratory alkalosis (from tachypnea) develops into acidosis as
the patient tires.
3. Fine inspiratory crackles are auscultated.
4. The patient is often confused and lethargic.
5. If ARDSis not reversed, eventually hypoxemia leads to decreased
cardiac output, shock, and death.
ACUTE RESPIRATORY DISTRESS
SYNDROME/ ACUTE LUNG INJURY
Complications:
Complications that can result from ARDS include heart failure; pneumothorax related
to mechanical ventilation, infection, and disseminated intravascular coagulation (DIC).
The death rate for ARDS in the past was 100%. With newer treatments, it is now closer
to 40%. Most patients who survive ARDS recover completely.

Diagnostic Tests:
▪Diagnosis is made based on history of a causative injury, physical
examination, chest x-ray examination, CT scan, and blood gas analysis.
▪An ECG is done to rule out a cardiac-related cause.
ACUTE RESPIRATORY DISTRESS
SYNDROME/ ACUTE LUNG INJURY
Therapeutic Measures
▪The patient with ARDS is cared for in an ICU.
▪Treatment is supportive and also aimed at the underlying cause.
▪Oxygen therapy is adjusted on the basis of repeated ABG results.
▪Noninvasive positive pressure ventilation or intubation and mechanical
ventilation are necessary in most cases, with the use of positive end-
expiratory pressure (PEEP) to keep the alveoli open.
▪Diuretics may be used to reduce pulmonary edema
ACUTE RESPIRATORY DISTRESS
SYNDROME/ ACUTE LUNG INJURY
▪ IV fluids are administered if blood pressure or urine output is low.
▪ A pulmonary artery catheter may be used to monitor hemodynamic status.
▪ If infection or sepsis is the underlying cause, antibiotics are administered.
▪Tube feeding or total parenteral nutrition (TPN) maintains nutritional status while the patient is
acutely ill.
▪Positioning the patient with the less involved lung in the dependent position (“good lung down”)
allows the better lung to be well perfused with blood and may increase PaO2.
▪ Prone positioning has also been shown to increase oxygenation and reduce the death rate in
patients with ARDS.
PLEURAL EFFUSION
 PLEURAL EFFUSION
Pleural effusion refers to the accumulation of
fluid in the pleural cavity.
Pathophysiology
Caused by at least one of the five
following mechanisms:
🢝 Increased pressure in pulmonary
capillaries (e.g. heart failure, massive PE)
🢝 Increased capillary permeability (e.g.
pneumonia, malignancy, infection,
pancreatitis)
🢝Increased intrapleural negative pressure
(e.g. atelectasis, trapped lung)
🢝Decreased plasma osmotic pressure (e.g.
hypoalbuminemia, hypoproteinemia, cirrhosis)
🢝Impaired lymphatic drainage of the pleural
space (e.g. pleural malignancy or infection)

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PLEURAL EFFUSION
Signs and symptoms.
1. Shortness Of Breath
2. Pleuritic Chest Pain
3. Tachypnea
4. Hypoxemia If Ventilation Is Impaired
5. Dullness To Percussion
6. Decreased Breath Sounds Over The Involved Area

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PLEURAL EFFUSION
Diagnostic Studies
1. Chest Radiograph.
2. Ultrasound, CT Scan
3. Thoracentesis
PLEURAL EFFUSION
Management
1. Treat the underlying cause.
2. Removal of the pleural effusion
by thoracentesis.
3. Chest tube placement or surgery may be
indicated depending on the etiology and
size.
4. Primary indication for therapeutic
thoracentesis is the relief of dyspnea.
CHEST TRUMA
PNEUMOTHORAX
Air enters the pleural space between the visceral and parietal pleurae, producing
partial or complete lung collapse.
Type of Pneumothorax
SPONTANEOUS PNEUMOTHORAX ➔ If no injury is present, the pneumothorax is
considered spontaneous.
▪This occurs mostly in tall, thin individuals and in smokers.
▪Weakened lung tissue from lung cancer can also lead to pneumothorax.

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TRAUMATIC PNEUMOTHORAX ➔ OPEN PNEUMOTHORAX - If air can enter and
Penetrating trauma to the chest wall and escape through the opening in the pleural
parietal pleura allows air to enter the space, it is considered an open
pneumothorax.
pleural space.
CLOSED PNEUMOTHORAX- If air
This can occur as a result of a knife or
gunshot wound or from protruding collects in the space and is unable to
broken ribs. escape, a closed pneumothorax exists.
 TENSION PNEUMOTHORAX.

▪If a pneumothorax is closed, air, and

therefore tension, builds up in the pleural
space and is unable to escape.
▪As tension increases, pressure is placed
on the heart and great vessels, pushing
them away from the affected side of the
chest.
▪ This is called a mediastinal shift.
▪When the heart and vessels are
compressed, venous return to the heart
is impaired, resulting in reduced cardiac
output and symptoms of shock.
▪Tension pneumothorax is often related
to the high pressures present with
mechanical ventilation.
▪ It is a life-threatening emergency.
 HEMOTHORAX.
▪ The term hemothorax refers to the presence of
blood in the pleural space. This can occur with or
without accompanying pneumothorax (when they
occur together it is called a hemopneumothorax)

and is often the result of traumatic injury.

▪ Other causes include lung cancer, PE, and

anticoagulant use.
 HISTORY AND PHYSICAL FINDINGS
▪ Sudden dyspnea.
▪ Chest pain
▪ Tachypnea
▪ Tachycardia
▪ Restlessness, and anxiety.
▪ On examination, asymmetrical chest expansion on inhalation may be noted.
▪ Breath sounds may be absent or diminished on the affected side.
▪ In a “sucking” chest wound, air can be heard as it enters and leaves the
wound.
▪ If tension pneumothorax develops, the patient becomes hypoxemic and
hypotensive as well.
▪ The trachea may deviate to the unaffected side.
▪ Heart sounds may be muffled. Bradycardia and shock occur if emergency
intervention is not provided.
Diagnosis- Ultrasound, Chest radiograph, CT scan, ABG.
CONT,
Management
- Supplemental oxygen
- Chest tube
Tension pneumothorax
- life-threatening- Large-bore (16- or 18-gauge) needle should be placed into the
anterior second intercostal space.
FLAIL CHEST
Pathophysiology and Etiology:
▪ Occurs when multiple ribs are fractured.

▪As a result, the affected part of the chest collapses with

the negative pressure of inhalation and bulges with
exhalation.

▪ This is called paradoxical respiration, which may be

ineffective in ventilating the lungs and resulting in hypoxia.
FLAIL CHEST
Signs and Symptoms
▪The patient with a flail chest exhibits chest movement that is opposite to that usually
seen with respiration.
▪ The patient is dyspneic and anxious and may also be tachypneic and tachycardic.

Therapeutic Measures
Treatment includes supplemental oxygen and analgesics.
Intubation and mechanical ventilation.
Surgical stabilization of the ribs may be done in some cases.
THANK YOU