Chapter 32 Care of Patients with Noninfectious Lower Respiratory Problems Mrs. Marion Kreisel MSN, RN NU230 Adult Health 2 Fall 2011

Chronic Airflow Limitation • Chronic airflow limitation includes the chronic lung diseases: • Asthma • Chronic bronchitis • Pulmonary emphysema

Chronic Airflow Limitation

Chronic Obstructive Pulmonary Disease (COPD) • COPD includes: • Emphysema • Chronic Bronchitis • Characterized by bronchospasm and dyspnea • Tissue damage is

not

reversible and increases in severity, eventually leading to respiratory failure

Asthma • Intermittent disease • Reversible airflow obstruction and wheezing

Asthma: Pathophysiology • Bronchial asthma is an

intermittent

and

reversible

airflow obstruction affecting only the airways, not the alveoli • Airway obstruction occurs by: • Inflammation • Airway hyperresponsiveness

Asthma: Etiology • Classified into different types based on triggering events • Inflammation occurs in response to specific allergens, general irritants, microorganisms, and aspirin • Hyperresponsiveness occurs with exercise, URI, or unknown reasons

Asthma: Special Considerations • Older Adults: • Teach how to prevent asthma attacks • Women: • 35% higher incidence in women than men • Teach correct use of preventive and rescue drugs

Collaborative Management • Assessment: • History • Physical assessment and clinical manifestations: • Audible wheeze and increased respiratory rate • Increased cough • Use of accessory muscles • ”Barrel chest” from air trapping • Long breathing cycle • Cyanosis • Hypoxemia

Laboratory Assessment • Assess arterial blood gas level • Arterial oxygen level may decrease in acute asthma attack • Arterial carbon dioxide level may decrease early in the attack and increase later, indicating poor gas exchange

Pulmonary Function Tests • The most accurate measures for asthma are pulmonary function tests using spirometry including: • Forced vital capacity (FVC) • Forced expiratory volume in the first • second (FEV 1 ) • Peak expiratory flow rate (PEFR)

Residual Volume (RV) is increased

Interventions • Patient education: asthma is often an intermittent disease; with guided self-care, patients can co-manage this disease, increasing symptom-free periods and • decreasing the number and severity of attacks

Peak flow meter should be used twice daily by the patient if in red zone administer rescue drugs STAT!

• Personal drug therapy plan

Asthma: Drug Therapy • Pharmacologic management is based on the step category for severity and treatment • Preventive therapy drugs: • Used to change the airway responsiveness to prevent asthma attacks • Used every day, regardless of symptoms • Rescue drugs are used to actually stop an attack once it has started

Asthma: Drug Therapy • Bronchodilators: • Short-acting beta • Long-acting beta 2 2 agonists: rapid bronchodilation but short term relief (Proventil, Albuteral, Ventolin, Xopenex) agonists: slow bronchodilation with long term relief (Serevent & Foradil) Beta 2 agonists bind to the beta 2 adrenergic receptors & cause an increase in the intracellular level of Cyclic Adenosine Monophosphate (cAMP) This substance triggers smooth muscle relaxation

Asthma: Drug Therapy Cont: • Cholinergic antagonists: Purpose to both rescue & prevent asthma attacks (Atrovent & Spiriva) Cholinergic antagonists also known as Anticholinergic drugs block the parasympathetic nervous system resulting in increased bronchodilation and decreased pulmonary secreations.

• Methylxanthines: Used when other types of management are ineffective. • Need to monitor drug levels • High side effects • Example of Drugs: Theodur (theo

phylline

), (oxtri

phylline

), Choledyl

Asthma: Drug Therapy (Cont’d) • Anti-Inflammatory agents: decrease the inflammatory response in the airways. Can be given systemically or inhaled.

• Corticosteroids: decrease inflammatory & immune response (Flovent:Flutica sone , Pulmicort:Bude son ide, Asmanex: mometa sone ) • NSAIDs: inhaled or taken orally used to prevent asthma attacks taken on a regular basis. They are have different mechanisms of action (Nedo

crom

il:Tilade,

Crom

olyn Sodium:Intal NOT USED AS A RESCUE DRUG • Leukotriene antagonists: Oral drugs work to prevent attacks: Singulair: Monte

lukast

, Accolate:Zafir

lukast

• Immunodulators

Other Treatments for Asthma • Exercise and activity is recommended to promote ventilation and perfusion • Oxygen therapy is delivered via mask, nasal cannula, or endotracheal tube in acute asthma attack: • Heliox can improve oxygen therapy

Status Asthmaticus • Status asthmaticus is a severe, life-threatening, acute episode of airway obstruction that intensifies once it begins and often does not respond to common therapy • If the condition is not reversed, the patient may develop pneumothorax and cardiac or respiratory arrest • Treatment: IV fluids, potent systemic bronchodilator, steroids, epinephrine, and oxygen

Emphysema • Two major changes: loss of lung elasticity and hyperinflation of the lung • Dyspnea and the need for an increased respiratory rate • Air trapping caused by loss of elastic recoil in the alveolar walls, overstretching and enlargement of the alveoli into bullae, and collapse of small airways (bronchioles)

Chronic Bronchitis • Inflammation of the bronchi and bronchioles caused by chronic exposure to irritants, especially tobacco smoke • Inflammation, vasodilation, congestion, mucosal edema, and bronchospasm • Affects only the airways, not the alveoli • Production of large amounts of thick mucus

COPD: Etiology and Genetic Risk • Cigarette smoking • Air pollution

COPD: Complications • Hypoxemia • Acidosis • Respiratory infections • Cardiac failure, especially cor pulmonale • Cardiac dysrhythmias

COPD: Physical Assessment and Clinical Manifestations • History • General appearance • Respiratory changes • Cardiac changes

Dyspnea Assessment Tool

Laboratory Assessment • ABG values for abnormal oxygenation, ventilation, and acid-base status • Sputum samples • CBC • Hemoglobin and hematocrit blood tests • Serum electrolyte levels • Chest x-ray • Pulmonary function test

Impaired Gas Exchange • Nonsurgical interventions for chronic obstructive pulmonary disease: • Airway management • Monitoring patient at least every 2 hours • Cough enhancement • Oxygen therapy • Drug therapy • Pulmonary rehabilitation

Drug Therapy • Beta-adrenergic agents • Cholinergic antagonists • Methylxanthines • Corticosteroids • NSAIDs • Mucolytics

Surgical Management • Lung transplantation for end-stage patients • Preoperative care and testing • Operative procedure through a large midline incision or a transverse anterior thoracotomy • Postoperative care and close monitoring for complications

Ineffective Breathing Pattern • Assessment of patient for breathing pattern and respiratory infection • Interventions for the chronic obstructive pulmonary disease patient: • Specific breathing techniques • Positioning to help alleviate dyspnea • Energy conservation

Ineffective Airway Clearance • Assessment of breath sounds • Interventions for compromised breathing: • Careful use of drugs • Controlled coughing • Chest physiotherapy with postural drainage • Suctioning • Positioning

Ineffective Airway Clearance (Cont’d) • Hydration via beverage and humidifier • Flutter-valve mucus clearance devices • Tracheostomy

Imbalanced Nutrition • Interventions to achieve and maintain body weight: • Prevent protein-calorie malnutrition through dietary consultation • Monitor weight, skin condition, and serum prealbumin levels • Dyspnea management • Food selection to prevent weight loss

Anxiety • Interventions for increased anxiety: • Important to have patient understand that anxiety will worsen symptoms • Plan ways to deal with anxiety

Activity Intolerance • Interventions to increase activity level: • Encourage patient to pace activities and promote self-care • Do not rush through morning activities • Gradually increase activity • Use supplemental oxygen therapy

Potential for Pneumonia or Other Respiratory Infections • Risk is greater for older patients • Interventions include: • Avoidance of large crowds • Pneumonia vaccination • Yearly influenza vaccine

COPD: Community-Based Care • Home care management: • Long-term use of oxygen • Pulmonary rehabilitation program • Health teaching: • Drug therapy • Manifestations of infection • Breathing techniques • Relaxation therapy

Cystic Fibrosis • Genetic disease affecting many organs, lethally impairing pulmonary function • Present from birth, first seen in early childhood, although almost half of all people with cystic fibrosis in the United States are adults • Error of chloride transport, producing thick mucus with low water content • Mucus plugs up glands, causing atrophy and organ dysfunction

Cystic Fibrosis

Cystic Fibrosis: Nonpulmonary Manifestations • Adults: usually smaller and thinner than average owing to malnutrition • Abdominal distention • Gastroesophageal reflux, rectal prolapse, foul-smelling stools, steatorrhea • Vitamin deficiencies • Diabetes mellitus

Cystic Fibrosis: Pulmonary Manifestations • Respiratory infections • Chest congestion • Limited exercise tolerance • Cough and sputum production • Use of accessory muscles • Decreased pulmonary function • Changes in chest x-ray result • Increased anteroposterior diameter

Cystic Fibrosis: Nonsurgical Interventions • Nutritional management: • Weight maintenance • Vitamin supplementation • Diabetes management • Pancreatic enzyme replacement • Prevention/maintenance therapy: • Chest physiotherapy • Positive expiratory pressure • Active cycle breathing technique • Exercise

Cystic Fibrosis: Nonsurgical Interventions (cont’d) • Exacerbation therapy: • Avoid mechanical ventilation • Supplemental oxygen • Heliox • Airway clearance techniques • Drug therapy • Patient education on prevention of exacerbation

Cystic Fibrosis: Surgical Management • Lung and/or pancreatic transplantation: • Does not cure the disease, because the genetic defect in chloride transport in other tissues and the upper airways remains • Extends life by 10 to 20 years • Patient is at continued risk for lethal pulmonary infections

Primary Pulmonary Hypertension (PPH) • PPH occurs in the absence of other lung disorders, and its cause is unknown • Pathologic problem is blood vessel constriction with increasing vascular resistance in the lung • The heart fails (cor pulmonale) • Without treatment, death occurs within 2 years

Pharmacologic Interventions • Warfarin therapy • Calcium channel blockers • Endothelin-receptor antagonists • Natural and synthetic prostacyclin agents • Digoxin and diuretics • Oxygen therapy

Interstitial Pulmonary Disease • Affects the alveoli, blood vessels, and surrounding support tissue of the lungs rather than the airways • Restrictive disease: thickened lung tissue, reduced gas exchange, “stiff” lungs that do not expand well • Slow onset of disease • Dyspnea is most common manifestation

Sarcoidosis • Granulomatous disorder of unknown cause that affects the lungs most often • Autoimmune responses in which the normally protective T-lymphocytes increase and damage lung tissue • Corticosteroids are the main type of therapy

Idiopathic Pulmonary Fibrosis • Common restrictive lung disease • Example of excessive wound healing • Inflammation that continues beyond normal healing time, causing extensive fibrosis and scarring • Mainstays of therapy: corticosteroids and other immunosuppressants

Occupational Pulmonary Disease • Can be caused by exposure to occupational or environmental fumes, dust, vapors, gases, bacterial or fungal antigens, or allergens • Worsened by cigarette smoke • Prevention through special respirators and adequate ventilation

Lung Cancer • A leading cause of cancer deaths worldwide • Poor long-term survival because of late stage diagnosis • Bronchogenic carcinomas • Paraneoplastic syndromes • Staged to assess size and extent of disease • Etiology and genetic risk

Lung Cancer (Cont’d) • Health promotion and maintenance • Assessment: • History • Pulmonary manifestations • Nonpulmonary manifestations • Psychosocial assessment • Diagnostic assessment

Lung Cancer: Nonsurgical Management • Chemotherapy • Targeted therapy • Radiation therapy • Photodynamic therapy

Lung Cancer: Surgical Management • Lobectomy • Pneumonectomy • Segmentectomy • Wedge resection

Common Incision Locations for Partial or Total Pneumonectomy

Chest Tube Placement

Chest Tube Chambers • Chamber 1: collects the fluid draining from the patient • Chamber 2: water seal that prevents air from entering the patient’s pleural space • Chamber 3: suction control of the system

Nursing Care After Thoracotomy • • Pain management • Respiratory management • Pneumonectomy care

Chest Tube Care: Make sure water is bubbling gently. If not quickly and carefully reposition patient to see if blockage is the reason. If this does not fix the problem this is an emergency and lead to excessive pressure in the chest.

•

Have at the bedside always sterile occlusive gauze and padded clamps incase tube becomes dislodged.

•

Be very careful when milking tube, it can cause more damage than good.

Interventions for Palliation • Oxygen therapy • Drug therapy • Radiation therapy • Thoracentesis and pleurodesis • Dyspnea management • Pain management • Hospice care

NCLEX TIME

Question 1 Which ethnic group is typically known to have the highest prevalence of smoking?

A. African Americans B. Asians C. Caucasians D. American Indians

Question 2 Approximately what percentage of the adult population in the United States smoke cigarettes? A. 5% B. 10% C. 20% D. 30%

Question 3 Which correctly reflects the prevalence of asthma when comparing the adult and child populations in the United States? The percentage of children who have asthma is ________ than adults.

A. Higher than B. Lower than C. The same as

Question 4 Which risk factor is responsible for the majority of deaths from lung cancer?

A. Cigarette smoking B. Occupational radiation exposure C. Chronic exposure to asbestos D. Air pollution

Question 5 A patient with a history of asthma is having shortness of breath. The nurse discovers that the peak flowmeter indicates a peak expiratory flow (PEF) reading that is in the red zone. The nurse should immediately: A. Repeat the PEF reading to verify the B.

results.

Take the patient’s vital signs.

C. Administer the rescue drugs.

D.

Notify the patient’s prescriber.