chapter 27: lower respiratory stuff Flashcards
Acute bronchitis
usually from viruses, but also irritants and asthma
-3 week cough
-NO fluid build up in lungs from consolidation
-may have fever, hoarseness, aches, dyspnea, pain
-gol of treatment is to relieve symptoms and prevent pneumonia
Perussis
Super contgious infection caused by Bordetella pertussis which attaches to and damages cilia
-TDAP vaccine is super important
“Whooping cough” –> might not be present in teens and adults –> happens more at night
contagious from onset to 3rd week or 5 days aft antibiotics
Pertussis phases
1) 1-2 weeks URT infection and nonproductive cough
2) weeks 2-10 paroxysyms of coughs
3) 2-3 weeks = weakness and less severe cough
Treatment do’s and dont’s for pertussis
-diagnose with cultures and PCR
-treat with macrolide or trimethoprim/sulfamethoxazole
-give antibiotics to ppl who were exposed too
-no cough suppressants or antihistamines
-no corticosteroids or bronchodilators
Pneumonia
-what?
why?
entryways
acute infection of lung parenchyma
-typically happens when immune defenses are compromised or overwhelmed –> chronic diseases make it worse
Pathogens enter lungs in 3 ways:
1. aspiration of normal flora from nasopharynx or oropharynx
2. inhalation of microbes in air (mycplasma pneumoniae)
3. hematogenous spread from other infection (streptococcus aureas from endocarditis)
Community acquired pneumonia (CAP)
Not from hospital (no hospitalization within 14 days)
Use CURB-65 to decide wheteher to treat in hospital
Confusion
U: BUN>20
Respiratory rate >30
Blood pressure <90/60
65 or older
Hospital acquired pneumonia (HAP)
-nonintubated patient –> 48+ hrs after admission
-ventilator associated pneumonia (VAP) –> 48+ hrs after intubation
Empiric antibiotics to treat
Viral and bacterial pneumonia
Viral
-most common
-mild to life threatening
Bacterial
-often hospitalized
Mycoplasma pneumonia has traits of viral and bacterial –> “atypical”
Aspiration Pneumonia
-stuff from moth or stomach enters lungs
-LOC, NG tubes, and swallowing issues
-usually more than one bacteria involved –> need antibiotics for G- and MRSA
-if acidic stuff from stomach causes issues –> “chem/noninfectious” –> no antibiotics
Necrotizing Pneumonia
-rare complication of lung infection turning tissue into thick liquid
-absesses and cavitization are possible
-resp failure and airway bleeding
-don’t really know reasons for it
-Staphylococcus, Klebisella, and Streptococcus involved
-long term antibiotics and possibly surgery
Opportunistic pneumonia
in immunocompromised patients
-protein malnourishment, HIV, radiation/chemo, long term corticosteroids
PJP pneumonia = fungal - slow, subtle onset
-tachycardia, fever, tachypnea, dyspnea, nonproductive cough, hypoxemia
-spreads to other organs (liver, bone marrow, lymph nodes, spleen, thyroid)
-doesn’t respond to antifungals–> use bactrim or sptra
CMV (herpes) can cause pneumonia
Pathophysiology for pneumonia
inflammation, neutrophils, edema, fluid leaks, hypoxemia
Atelectasis (nothing in alveoli) causes shortness of breath
Consolidation (fluid in alveoli) impairs gas exchange –> with treatment/time, macrophages get rid of this stuff
Manifestations of pneumonia
cough, fever, chills, dyspnea, tachypnea, and pleuritic chest pain
-cough may or may not be productive with any color of sputum
Old ppl might just be confused and have hypothermia rather than fever
Chest sounds of pneumonia
-course or fine crackles
If consolidation:
-bronchial breath sounds
-egophony
-increased fremitus
If pleural effusion
-dullness to percussion
Complications of pneumonia
MDR pathogens
atelectasis
pleurisy (inflammation of plaura)
pleural effusion
Bacteremia (bacterial blood infection)
pneumothorax (air in pleura makes lungs collapse)
acute respiratory failure
sepsis/septic shock
RARE:
-lung abscess (S. aureas and G-)
-emphysema (need antibiotics and drainage)
Diagnostic studies for pneumonia
history, phys exam and xray are enough to get started
-thoracentesis or bronchoscopy can get fluid for testing if patient isn’t responding to treatments
-ABGs and WBC assessment
-sputum sample to treat specific bacteria
Treatment of pneumonia
-antibiotics (should help in 48-72 hrs if uncomplicated)
-follow up xray in 6-8 weeks
-O2, analgesics, antipyretics as needed
-activity if tolerable
***usually not much you can do for viral pneumonia - resolves on its own in 3-4 days –> antiviral stuff can help if pneumonia from influenza or herpes
drug therapy for pneumonia
-empiric antibiotics including stuff to fight MDR pathogens and G- and G+
-switch to oral meds ASAP
-Get ppl out of hospital ASAP
-patient should be afebrile for 48-72 hrs before stopping treatment
Nutrition therapy for pneumonia
HYDRATION!!!!!!! –> thins and loosens secretions
Small, frequent meals to get enough cals for heightened metabolism –> eating can be hard bc shortness or breath
positions that prevent aspiration
upright and side-lying
ways to prevent pneumonia post op
-early mobilization
-incentive spirometer
-oral hygiene 2x a day with chlorhexidine swabs
Tuberculosis
infection caused by mycobacterium tuberculosis
-usually affects lungs, but can affect any organ
-kills poor people and HIV
Resistance is a huge problem –> MDR-TB (first line drugs) and XDR-TB (all the rest, including fluoroquinolones)
Mycobacterium tuberculosis facts
-contagion
-G+, aerobic, acid fast bacillus
-tiny droplets airborne (not super contagious though)
-humans are only reservoirs
-once in bronchioles/alveoli, Ghon lesion/focus forms (calcified TB source) to kill it (usually successful)
Classification of TB
Primary = initial immune response fails and disease progresses (“active”) w/in 2 yrs of infection
Reactivation = happens more than 2 yrs later
Latent = what it sounds like –> can be activated with immunosuppression, diabetes, bad nutrition, pregnancy, stress, aging, disease
How long after infection do symptoms show up?
cough progression
early symptoms
late symptoms?
2-3 weeks (except when it is acute)
starts dry then becomes productive
fatigue, malaise, weight loss, fever, chest pain
dyspnea and hemoptysis
*sometimes night sweats
TB presentation in old or HIV ppl
HIV: less likely to have signs of infection
-symptoms sometimes wrongly attributed to PJP
old ppl
-sometimes only display change in mental status
Miliary TB
widespread dissemination of the mycobacterium
-causes swelling of lymph, liver, spleen
-from primary or LTBI TB
Pleural TB
-extrapulmonary
-from primary or LTBI
-chest pain, fever, cough, PLEURAL EFFUSION
-emphysema not as common
-diagnosed with biopsy and AFB cultures
Potts syndrome
TB in spine
TB skin test
-use purified protein derivative (PPD) for M tuberculosis
-check 2-3 days later for induration (no redness)
-5 mm = positive
-2 step testing w/ Mantoux TST for baseline
Interferon-y release assays
-blood tests that detect INF-y release fom T cells
-only require one visit and are more accurate
-can’t differentiate bt LTBI and active
How accurate are chest xrays for TB diagnosing?
What about bacteriologic studies?
-chest xrays aren’t great
-gold standard! –> 3 specimen 8-24 hrs apart –> can take a long time though
How long are TB ppl contagious?
-if sputum smear is positive, they’re contagious for first 2 weeks after starting treatment
Drug therapy for TB
Initial and continuation phase
Initial:
-4 drug regimen for 8 weeks
-isoniazid, rifampin, pyrazinamide, ethambutol
Continuation:
-2 drugs for 18 weeks
-isoniazid and rifampin
CAUTION: ALC AND ISONIAZID DON’T MIX
-nonviral hepatitis is a possible side effect
Drug treatment for MDR and XDR TB
-guided by sensitivity testing
MDR
-usually 5 drugs for 6 months
-then 4 drugs for 18-24 months
Sirturo and Deltyba treat MDR and XDR
Directly observed therapy (DOT)
-Watch them take the meds
-Nonadherance is big issue with spread of MDR-TB
-can use combo pills to make it easier for ppl
Latent TB drug treatment
-usually only need 1 drug (typically isoniazid for 9 months)
-6 month regimen is less effective, but better for adherence
-ppl w/ HIV or fiberobtic chest lesions need full 9 months
-3 month of isoniazid AND rifapentine if no MDR
-4 month rifampin if resistant to isoniazid
Bacille Calmette-Guerin (BCG) vaccine
-live attenuated strain of Mycobacterium bovis
Not used so much in U.S.
-no help with pulmonary TB
-interferes with TB skin test
-no effect on IGRA though
Who do you report positive TB tests to?
public health authorities
3 things to do if someone comes into ER with suspected TB
- airborne precautions (fitted HEPA masks)
- chest xray, sputum smear, culture
- drug therapy
Ambulatory care
-its ok to go home if fam is already exposed
-sputum for AFB every month until 2 in a row are neg
-reduce exposing others –> spend time outside
-stick to drug regimen
-teach how to recognize relapses
-STOP SMOKING
Atypical Mycobacteria
-acid fast mycobacteria that cause pulmonary disease
-not airborne or droplet
-cough, SOB, weight loss, blood-tinged sputum
-can’t differentiate bt this and TB w/o culture
Pulmonary Fungal Infections
-E.g. fungal pneumonia caused by endemic fungi (e.g. Coccidioides)
-Opportunistic fungal infections
Inhalation of spores –> not contagious
similar to pneumonia
antifungals given
-Amphotericin B IV for serious systemic infection
Lung abscess
necrosis of lung tissue
-usually from aspirated bacteria, but also from IVs, cancer, pulmonary emboli, TB, parasites, and fungi
usually more than one anaerobic microbe in back part of upper lobe of lung
foul smelling sputum
“necrotizing pneumonia”
manifestations and lung sounds of lung abscess
Stand out symptoms:
-purulent sputum that smells and tastes gross
-hemoptysis when abscesses pop
Others:
-fever, chills, preostration, night sweats, pleuritic pain, dyspnea, weight loss
Lung sounds:
-less lung sounds
-bronchial sounds might move peripherally
-crackles in later stages
spreading of lung abscess
-goes through blood
-bronchopulmonary fistula, bronchiectasis, and empyema from popping of abscess into pleural cavity
Diagnostic study of lung abscess
- chest xray
-CT scan helps too
-sputum isn’t great bc it’ll have oral flora if coughed up
-Bronchoscopy can help get sample and look for cancer
-pleural fluid and blood can help identify the microbe
Nursing care for lung abscess
Doctor care
-monitor vitals and look for hypoxemia
-give O2 and antibiotics
-food, rest, water
-DONT do chest PT or postural drainage
-percutaneous drainage or surgery if unresponsive to drugs
Lung Tumors (not cancer)
Hamartomas = slow, benign tumor made of fiber, fat, and blood vessels
Mucous gland adenoma = benign tumor made of columbar cystic spaces in bronchi
Mesotheliomas = may or may not be benign –> visceral pleura –> melignant ones assoc w/ asbestos
Fractured ribs
-most common injury from blunt trauma
-ribs 5-9
-pain, shallow breaths, possibly atelectasis and pneumonia
Don’t strap chest –> limits ability to expand
Use pain meds, deep breathing, spirometer
Flail chest
-happens when 3+ ribs in 2+ places are fractured, forming unstable segment
-that part moves opposite of normal chest
-tachycardia, shallow breaths
-treat like any rib fracture
Pneumothorax
air enters pleural cavity ruining the neg pressure
-causes lung collapse
open = entering through chest wall
closed = no external wound
tachycardia, dyspnea, air hunger, low O2, no breath sounds
Spontaneous pneumothorax
rupture of blebs on lung surface
-blebs are there more in smokers
-tall, thin males get it more
Iatrogenic pneumothorax
puncture during med procedures
-barotrauma from excessive ventilation
Tension pneumothorax
air can’t escape from pleural space and pressure keeps rising
-crushes lung on affected side and pushes mediastinum to other side where it crushes other lung –> also heart is being crushed
can happen with chest tubes that’re clamped
MED EMERGENCy!!! –> Needle decompression and chest tube insertion
Hemothorax
blood accumulation in pleural space –> needs to be drained –> blood may be reusable
Chylothorax
lymph fluid in pleural space
-usually happens bc trauma or cancer fucks with thoracic duct
-need meds and/or surgery
Treatment of pneumothorax
-cover wound secured on 3 sides
-if impaled, don’t remove object
-chest tube connected to water-seal drainage
-maybe surgery
Chest tube dimensions
20” long
36-40F for draining blood
24-36F for draining fluid
12-24F for draining air
10-14F = pigtail (also for air)
inserting chest tube
patient is upright (30-60*) with arms above head
-incision over a rib and tube goes over rib
-sutures it in place
-sealed with airtight petroleum gauze
Flutter or Heimlich valve
device used to remove air from pleural space
-can walk around with it –> bag under clothes
Pleural Drainage systems 3 compartments
- collection chamber
- water seal chamber which acts as a one way valve
- suction control chamber: wet or dry
-wet suction determined by water level
-dry suction uses restriction device or regulator
should we be clamping chest tubes during transport?
nah bro
-way riskier bc of tension pneumonia
-just reestablish water seal ASAP
When can you clamp chest tubes
just temporarily when changing the drainage apparatus or checking for air leaks
risks of quickly removing 1-1.5 L through chest tube
-reexpansion pulmonary edema
-severe hypotension
what happens when air leaks into tissue around chest tube?
subcutaneous emphysema –> can lead to swelling of head and neck –> obstruction
how much is too much drainage from chest tube?
over 200 ml
Call HCP!
thoracotomy
surgical incision to get to heart, lungs, esophagus, throacic aorta, or anterior spine
1. sternotomy for heart
2. posterolateral for lung
3. anterolateral for trauma victims
What to check before thoracotomy
-cardiopulmonary status
-chest xray
ECG
ABG
CBC
PT/INR
aPTT
After a thoractotomy
PAIN MANAGEMENT –> MOST PAINFUL INCISION
-assess breathing, sputum, vitals, wound
Thoracentesis
aspiration of intrapleural fluid for diagnostic purposes
-usually no more than 1000 to 1200
Restrictive respiratory disorders
-side note: whats a hallmark of obstructive disorders?
extrapulmonary
intrapulmonary = lungs or pleura
Decreased total lung capacity (stops expansion)
Obstructive: if obstructive, decreased forced expiratory volume
Atelectasis
collapsed, airless alveoli
-often bc airways blocked by secretions
-post op patients
Pleurisy
inflammation of pleura
-abrupt, sharp pain on inhalation
-shallow rapid breathing
usually a side effect, not a primary condition
Pleural effusion types
***usually bc of malignancy
transudate = pale yellow fluid w/o cells or protein –> usually HF or low albumin
exudate = inflammatory rxn causes increased capillary permeability
empyema = purulent fluid in pleura due to pneumonia, TB, lung abscesses, and infected wounds
Pleural effusion manifestation
pain that doesn’t radiate
less movement on one side
Interstitial lung disease
tissue bt air sacs of lungs is inflammed or scarred
-200 dif disorders
Idiopathic pulmonary fibrosis
SMOKING CAUSES IT
WEIGHT LOSS AND FATIGUE AND CLUBBING
DO A CHEST XRAY AND VATS
O2 therapy and pulmonary rehab
no real cure –> ppl die –> 30-50% 5 yr survival
STEROIDS
Sarcoidosis
granulomatis disease –> unknown cause
-can affect a bunch of dif organs
-follow up with pulmonary function, xray, and CT
**ppl usually die with it, not of it
**black men get this
STEROIDS
pulmonary edema
usually bc of HF
-fluid in alveoli and interstitial spaces
Pulmonary embolism
***cancer is #1 cause bc of extra cells
-blocking of pulmonary arteries with thrombus, fat, or air
-DVT/VTE
-sometimes upper extremety DVT from catheters/arterial lines
manifestations of pulmonary emboli
dyspnea and mild hypoxemia
if it gets real bad there’s change in mental status, hypotension, acidosis, and feeling of impending doom
pulmonary embolism complication
Pulmonary infarction (death of lung tissue) –> usually accompanied by pleural effusion
Pulmonary hypertesion –> can lead to hypertrophy of right ventricle
diagnostic study for pulmonary embolism
D-dimer –> not sensitive or specific
helical CT scan!!!!!!!!!!!!!!
V/Q scan = IV radioisotope and Radioactive gas (perfusion and ventilation)
Important tests for pulmonary embolism that aren’t diagnostic
ABG
chest xray
ECG
troponin
B-type natriuretic peptide
Treatment for PE: supporting cardiopulmonary status
O2 = intubation/ mechanical ventilation
pulmonary hygiene = prevent atelectasis
shock = fluids and vasopressors
HF = diuretics
Pain = opioids
drug therapy for PE
ANTICOAGULANTS + blood thiiners (heparin and warfarin)
Fibrinolytic agents to dissolve clot (tPA and activase)
surgical therapy for PE
If big: pulmonary embolectomy
-good if hemodynamically unstable and thrombolytic therapy is contraindicted
Percutaneous catheter embolectomy or endovascular ultrasound delivered thrombolysis
Inferior vena cava filter for high risk ppl who can’t take anticoagulants –> stops migration of clots into pulmonary system
Nursing management of PE
Prevention
-compression devices
-early ambulation
-anticoagulants
Immediate treatment
-bed rest in semi fowlers
-check cardiopulmonary status
-give O2, IV fluids, meds
-Monitor: coagulation and complications
Pulmonary hypertension
high pulmonary artery pressure due to high resistance
MAP
-Normal = 12-16
-HTN = over 25 at rest; over 30 exercising
can be main or secondary disease (r sided hf)
5 classess of pulmonary hypertension
1) a/w meds, disease, genetics, idiopathic
2) left sided HF
3) lungs and hypoxemia
4) CV system and thromboembolic occlusion
5) multifactorial (hematologic or metabolic involvement)
Idiopathic pulmonary arterial hypertension (IPAH)
Results in right HF and death if untreated
Possible causes
-CT disease, cirrhosis, HIV
Results in
-vascular scarring, endothelial dysfunction, smooth muscle proliferation
affects females more
Manifestations of IPAH
dyspnea and fatigue
-chest pain, dizziness, syncope
Eventually dyspnea at rest and right ventricle hypertrophy
Diagnostic studies for IPAH
RIGHT SIDED HEART CATHETERIZATION
-ECG, chest xray, PFTs, echo, CT
Early recognition and drug therapy for IPAH
Note unexplained SOB, syncope, chest pain, and edema
Drugs
-pulmonary vasodilation
-manage edema
-prevent thrombi
-prevent hypoxia
surgical interventions for IPAH
Pulmonary thromboendarterectomy (PTE)
-Atrial septostomy (AS) = palliative
-lung transplant
Secondary pulmnoary arterial hypertension (SPAH)
Chronic increase in pulmonary artery pressure from other disease
-parenchymal lung disease
-LV dysfunction
-intracardiac shunts
-chronic PE
-CT disease
Symptoms, diagnosis and treatment of SPAH
dyspnea, fatigue, chest pain, right hypertrophy and HF
Diagnosis = same as IPAH
Treatment: underyig cause –> if irreversible, IPAH therapies
Cor Pulmonale
Enlarged right ventricle secondary to disorder of respiratory system; COPD
-usually already has pulmonary hypertension –> maybe HF too
Manifests: same as IPAH –> sometimes polycythemia
-if HF: water retension and big liver
Lung transplant is for what?
ESLD
-COPD, pulmonary fibrosis, cystic fibrosis, IPAH, alpha antitrypsin deficiency
Preop for lung transplant
evaluateion
ensure no contraindictions (cancer, HIV, Hep B/C, psych issues, smoker, poor nutrition)
-need to adhere w/ post op regimen
UNOS gives LAS score to determine who gets lungs
surgery types for lug transplant
single lung
bilateral lungs
heart-lungs
lobes from living related donors
lung transplant rejection
Acute: 5-10 days
-fever, fatigue, dry cough, O2 desaturation
Chronic: Bronghiolitis obliterans
-progressive airflow obstruction unresponsive to bronchodilators and corticosteroids
