Joseph Krafft MSN APN-BC CCRN

Functions:
Larynx: maintains an open airway, routes food and air appropriately, assists in sound production Trachea: transports air to and from lungs Bronchi: branch into lungs Lungs: transport air to alveoli for gas exchange

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two areas of different pressure communicate, gas will move from the area of higher pressure to the area of lower pressure This movement of air causes wind when a high pressure system is near a low pressure system in the atmosphere

Brain signals the phrenic nerve Phrenic nerve stimulates the diaphragm (muscle) to contract When diaphragm contracts, it moves down, making the thoracic cavity larger

When the diaphragm contracts, it moves down, increasing the volume of the thoracic cavity When the volume increases, the pressure inside decreases Air moves from an area of higher pressure, the atmosphere, to an area of lower pressure, the lungs Pressure within the lungs is called intrapulmonary pressure

Exhalation occurs when the phrenic nerve stimulus stops The diaphragm relaxes and moves up in the chest This reduces the volume of the thoracic cavity When volume decreases, intrapulmonary pressure increases Air flows out of the lungs to the lower atmospheric pressure

Remember, this is normally an unconscious process Lungs naturally recoil, so exhalation restores the lungs to their resting position However, in respiratory distress, particularly with airway obstruction, exhalation can create increased work of breathing as the abdominal muscles try to force air out of the lungs

Hypoxia : Decreased levels of oxygen in the tissues Hypoxemia : Decreased levels of oxygen in arterial blood Hypercapnia : Increased levels of CO2 in the blood Hypocapnia : Decreased levels of CO2 in the blood Dyspnea : Difficulty breathing Tachypnea : Rapid rate of breathing Cyanosis : Bluish discoloration of skin and mucous membranes due to poor oxygenation of the blood Hemoptysis : Blood in the sputum

Atelectasis is caused by a blockage of the air passages (bronchus or bronchioles) or by pressure on the outside of the lung. Depending on the severity of the atelectasis, there may be no obvious signs or symptoms. If you do experience signs and symptoms, they may include:

Breathing difficulty Chest pain Cough

Anesthesia Foreign object in the airway (most common in children) Lung diseases Mucus that plugs the airway Pressure on the lung caused by buildup of fluid between the ribs and the lungs Prolonged bed rest with few changes in position Shallow breathing Tumors that obstruct the airway may lead to atelectasis

 Inspection

cough delayed chest expansion on the affected side increased respiratory rate increased pulse possible cyanosis

Palpation
chest expansion decreased on the affected side tactile fremitus decreased or absent over the involved area with a large collapse, the trachea may deviate or shift toward the affected area

Auscultation
breath sounds decreased or absent over involved area no adventitious sounds if bronchus is obstructed occasional fine crackles if bronchus is patent

Deep Breathing and Coughing

Incentive Spirometry

Impaired gas exchange Ineffective airway clearance Ineffective breathing pattern

Inflammation of the lung parenchyma 6th Leading Cause of Death in USA. Incidence and mortality highest among older adults and people with debilitating diseases. Presents as infectious or noninfectious. Classified as Community-Acquired, Nosocomial, or Opportunistic. of all cases.

Streptococcus pneumoniae implicated in 75%

Lower Respiratory Tract should be sterile. Most common mode of entry is aspiration of oropharyngeal secretions containing infectious microbes. Contaminated water, droplet transmission, and septicemic transmissions can also occur. Microorganism colonization of the alveoli results in antigen-antibody release, resulting in inflammation, edema, and exudate accumulation, which infiltrates and obstructs airway flow.

Acute Bacterial:
Typically results from Strept. pneumoniae. Spread via person-to-person contact, inhaled via the individuals own airway, or droplet. Results in alveolar edema and infiltration with exudate. Consolidation occurs from alveolar and bronchial filling with blood cells, fibrin, and bacteria. Lower Lobes (Lobar Pneumonia) most commonly affected

Manifests as highly acute, rapid onset of chills, fever, and cough (rust or purulent expectorant). Pleuritic (sharp) CP w/ breathing is typical. Lung Sounds are diminished w/ crackles. Dyspnea and cyanosis noted in gas exchange impairment. Bronchopneumonia presents with a low-grade fever, cough, and scattered cracklesless acute in presentation. In the older adult, S/S may be different because of altered immune capabilities: S/S of hypoxia are common.

Causative organism mycoplasma pneumoniae Develop patchy inflammatory changes in the alveoli Young adults primary affected population Highly contagious S&S: fever,H/A, myalgias, arthralgias, cough Referred to as Walking Pneumonia

Form of bronchopneumonia caused by Legionella

pneumophilia- found in (warm, long-standing) water.

1st recognized after spreading rapidly at the 1976 American Legion Convention. Smokers, older adults, and people with chronic diseases are most susceptible. Manifests as dry cough, dyspnea, general malaise, chills/fever, HA, confusion, anorexia and diarrhea. Consolidation is patchy or lobar. Mortality rate is 31% in non-immunocompetent; 81% if immunocompromised.

Influenza and adenovirus most common organisms Lung involvement is limited to the alveoli septum and interstitial spaces Occurs in community epidemics S&S: Flu like sx, H/A, fever, fatigue, malaise and muscle aching

Occurs in 75-80% of people with AIDS Produces patchy involvement throughout the lungs causing alveoli to thicken, become edematous and fill with foamy protein rich fluid Abrupt onset with fever, tachypnea, and SOB

Chemical and bacterial pneumonia from aspiration of gastric contents into the lungs Risk factors: emergency surgery, obstetric procedures, depressed cough and gag reflex, impaired swallowing, enteral nutrition

Sputum Gram Stain Sputum C&S: Ensure Lower Airway Sample Not Oropharyngeal WBC (>10,000 = Infection) Arterial Blood Gases (ABGs) SpO2 CXR FOB: Fiberoptic Bronchoscopy

Pneumococcal vaccine: recommended for those >65 y/o or those with chronic and debilitating diseases. Medications used for treatment designed to eradicate infection (ATBx) and improve ventilation (bronchodilators). Most ATBx carry the adverse effects of diarrhea, candidal infection, and superinfection.

Increase fluids up to 3L/day. Incentive Spirometry Endotracheal suctioning Oxygenation Chest Physiotherapy

Postural Drainage Chest Percussion Controlled Coughing Deep Breathing

Health promotion and prevention are paramount! Health History should concentrate on current symptoms, characteristics of cough, sputum, etc. Physical exam should concentrate on respiratory system and the systems involved in pneumonia and hypoxia.

Ineffective Airway Clearance, Ineffective Breathing Pattern, Impaired Gas Exchange, Knowledge Deficit Activity Intolerance. Remember to prioritize via ABC Physiologic Psychosocial.

Chronic, recurrent infectious BACTERIAL disease typically infecting the lungs as a result of Mycobacterium tuberculosis. Prevalence decreased with a resurgence in the late 1980s and early 1990s as a result of AIDS. Prevalence continues to decline as a result of improved surveillance and prevention efforts. HIV, and disadvantaged populations Highest among immigrants, those infected w/HIV

More than 2 billion people, equal to onethird of the worlds population, are infected with TB bacilli, the microbes that cause TB. 1 in 10 people infected with TB bacilli will become sick with active TB in their lifetime 1.8 million people died from TB in 2008, including 500 000 people with HIV - equal to 4500 deaths a day

Transmitted via droplet transmission when person speaks, coughs, or sneezes, or sings. Droplets can suspend in air for hours, highlighting the significance of isolation. The closer individuals are in contact with persons infected, the higher the risk for transmission. Droplet nuclei containing 1-3 bacilli implant in an alveolus or bronchiole, usually in an upper lobe. Local inflammation results from rapid bacterial multiplication.

Cough (sometimes producing phlegm) Coughing up blood Excessive sweating, especially at night Fatigue Fever Unintentional weight loss

Phagocytic (Neutrophils/Macrophages) surround bacilli isolate but cannot destroy the bacilli, creating a granulomatous lesion called a tubercle. The surrounding tissue dies from infection, necrosing into a Swiss Cheese appearance called Caseous Necrosis. Scar tissue can develop around the tubercle; the bacilli remains encapsulated and calcifies. It lies dormant and the individual is a carrier of the disease, or it becomes active (with improper immune function) and the individual is actively infected.

TB can also spread via the blood and lymphatics to the GU system, resulting in widespread inflammation and destruction of the kidneys, ureters, and bladder TB Meningitis, with resulting inflammation of the subarachnoid space (observe for changes in LOC, irritability, fever, anorexia, HA, vomiting, convulsions and coma; or as

Erodes and collapses the vertebral bodies in spondylitis.

Patient should be maintained on Airborne Precautions. PPD is used as a screening tool, + does not mean the patient is actively infected. Mantoux Test is read within 48-72 hours with the area of induration (raised, scabbie erythema) is measured in millimeters. Patients must be educated to complete drug regimens as prescribed.

A positive skin test indicates TB exposure and an inactive infection

People who have been exposed to TB should be skin tested immediately and have a follow-up test at a later date, if the first test is negative.

Some countries with a high incidence of TB give people a BCG vaccination to prevent TB. However, the effectiveness of this vaccine is controversial and it is not routinely used in the United States. People who have had BCG will have a positive PPD skin test and will need a chest x-ray for screening.

3 Sputum samples with + AFB is the ONLY 100% diagnostic test for TB. Collect sputum in AM x 3 days C&S will be positive for M. tuberculosis Chest X-ray reveals dense lesions in the apical and posterior segments of the upper lobe w/ possible cavitary formation. Before initiating Drug therapy, LFTs, Optic Examination, and Audiometric Testing should be performed.

Isoniazid (Nydrazid) ((INH) Rifampin (Rifadin, Rimactane) (RIF) Ethambutol (Myambutol) (EMB) Pyrazinamide (PZA)

Regimens for treating TB have an initial phase of 2 months, followed by a choice of several options for the continuation phase of either 4 or 7 months.

Amikacin (Amikin) Ethionamide (Trecator) Moxifloxacin (Avelox) Para-aminosalicylic acid Streptomycin

Adverse Effects of these Rxs include Hepatotoxicity Check Liver Function Tests Avoid ETOH and high doses of Tylenol Orange discoloration of body fluids (important for contact lens wearerseducate client).

Prophylactic Tx used for carriers and those exposed to carriers (INH 300mg PO QD x 6-12 months) INH, Rifampin, and Pyrazinamide PO QD x 2 months; then x 4months w/ INH & Rifampin.

Resistance to TB drugs can occur when these drugs are misused or mismanaged. Examples include When patients do not complete their full course of treatment; When health-care providers prescribe the wrong treatment, the wrong dose, or wrong length of time for taking the drugs; When the supply of drugs is not always available When the drugs are of poor quality.

Multidrug-resistant TB (MDR TB) is TB that is resistant to at least two of the best anti-TB drugs, isoniazid and rifampin. These drugs are considered first-line drugs and are used to treat all persons with TB disease.

Education and screening are paramount. 9-10 months of INH Tx reduces TB by 90%+.

Clinical improvement gauged via repeat CXRs.

Nursing Diagnosis must include Knowledge Deficit (educate about disease process and the toxicity of medications);

Ineffective Therapeutic Regimen Management Provide community links and resources for the patient and educate the client about proper medication schedule and adherence Risk for (Communicable) Infection (place the patient on Airborne Precautions in a room with airflow control