Chapter 30 & 31 RTI, Neoplasms, Childhood disorders, and Disorders of Ventilation Flashcards
Upper respiratory tract infection
- What part of the body is affected potentially?
- Common offenders
- Some illnesses affect both upper and lower tracts
- With URTI the nose, oropharynx, and larynx are commonly affected
- Offending illnesses include colds, allergies, and sinusitis
Lower respiratory tract infections
- What parts of the body are affected?
- Common illnesses?
- Some illnesses affect upper and lower tracts
- The airways and lungs
- Pneumonias, pleural effusions, and empyema
The Common Cold
- What type of infection?
- What are some common offending agents?
- Most common transmission? Others
- The common cold is a viral infection of the upper respiratory tract.
- Some common viruses that cause the common cold include Coronavirus, respiratory syncytial virus (RSV), rhinovirus, parainfluenza viruses, and adenoviruses.
- The most common way of spread is via hands. Washing hands greatly reduces risk of spread. Coughing, sneezing
Rhinitis
Inflammation of the nasal mucosa
Sinusitis
Inflammation of the paranasal sinuses
All the sinuses in the skull are connected. What are their names?
- Paranasal
- Maxillary
- Frontal
- Sphenoid
- Ethmoid
Influenza A & B
- What type of illness
- Who can be affected
- A VS B
- Treatment
- Virus
- Humans and animals can be affected
- Causes more severe illness than with influenza B
- There is flu vaccines, Oseltamivir (Tamiflu), Zanamivir
Two types of flu vaccines
- Intramuscular injection (classic)
- Intranasal (recent) - often better tolerated by kids
Pneumonia
- What is it?
- Common causes?
- Respiratory disorders involving inflammation of the lung structures (alveoli and bronchioles)
- Can be caused by infectious agents (bacteria and viral) and by noninfectious agents (aspiration, smoke inhalation, chemical)
Tubercle bacillus
- What is the usual progression of primary TB?
- What happens if immunity is not developed?
- What is secondary pneumonia?
- Positive TB skin test
- What is M. tuberculosis?
- Inhalation of the TB pathogen travels to the lungs and causes the infection. The body mounts an immune response to fight the infection. Most people develop immunity and are done with the disease.
- If immunity was not developed, then the immune system still does it’s job and encases the TB pathogens in a Ghon complex (a cheesy like capsule that stops the spread and action of the pathogen). After awhile this Ghon complex heals over and the TB lies dormant.
- Secondary TB is when there is reinfection (TB pathogens are reintroduced into the body) or when the host’s immune system diminishes enough that the dormant capsules in the lungs break free and cause issues again.
- A positive TB skin test indicates the patient has either had past exposure and has dormant TB, developed immunity to the pathogen, or has active TB.
- M. Tuberculosis is the pathogen that affects humans. Best spreads in conditions of tight living arrangements via cough
Histoplasmosis
- What type of pathogen causes this?
- How is this pathogen spread?
- Where areas is this most commonly found it?
- Histoplasmosis is a fungal infection
- The pathogen is spread via spores that are transmitted via airborne means. Typically, there is an increased risk of the spread when soil with large amounts of bird or bat droppings are disturbed.
- Areas with large amounts of bird or bat droppings that are humid and moist. Eastern U.S., Central and South America, Africa, Asia, and Australia
Histoplasmosis
- What is it?
- What are some common symptoms?
- Histoplasmosis is a fungal infection that is transmitted via airborne means. It is found most commonly in warm, moist environments with large amounts of birds or bats. Stirring up the droppings increases the risk of transmission.
- Symptoms - largely asymptomatic. If symptomatic - fever, cough, fatigue. Immunocompromised individuals are at higher risk.
Types of fungi
- How are most fungi spread?
Types - yeasts (round, reproduce via buds). Molds (form tubular structures called hyphae, reproduce via branching or spores). Dimorphic fungi - can grow as yeasts or molds depending on the temperature.
Spread - most fungi spread via inhalation
Community-Acquired Pneumonia
- What is it?
- What is the most common pathogen that causes CAP?
- How is CAP diagnosed?
- Treatment
- Infection that begins outside the hospital or has been diagnosed 48 hours prior to admission. Can be bacterial or viral.
- S. pneumoniae is the most common pathogen causing CAP. H. influenzae, S. aureus, and Klebsiella also are common bacterial causes. Common viral causes include influenza virus, rhinovirus, and RSV.
- CAP is diagnosed in different ways depending on the age and overall health of the affected individual. Individuals that are otherwise healthy and are younger than 65 can be diagnosed based on history and physical, chest x-rays, and knowledge of community microorganisms. Individuals that are older than 65 or have comorbities are more commonly diagnosed with sputum samples and blood smears to identify the offending pathogen.
- Treatment of CAP that does not require hospitalization is done via empiric antibiotic therapy. More intensive care requirements dictate the need for determining the offending agent and lining up appropriate antibiotic therapy.
How does CAP diagnosis vary among populations?
CAP diagnosis depends upon the age and overall health of the affected individual.
- Individuals that are younger than 65 and are generally healthy can be diagnosed by history and physical, chest x-ray, and knowledge of community pathogens at that time.
- Individuals that are older than 65 or have comorbities may require more extensive testing in addition to the H&P, chest x-ray, and community knowledge. Sputum samples or blood smears can identify offending microorganisms and better direct treatment.
What is the most common cause of community acquired pneumonia?
The most common bacterial cause of CAP and most common cause in general is Streptococcus pneumoniae followed by staphylococcal.
The most common viral cause of CAP is Influenza virus
Pneumonia is most commonly spread via resp droplets
Hospital-acquired pneumonia
- Diagnosis criteria
- Pathogens and treatment
HAP is a lower respiratory tract infection that was not present on admission to the hospital. Infections that occur 48 hours or more after admission are considered HAP. Most HAP cases are bacterial in nature and are caused by different pathogens that CAP. Many of these pathogen require antibiotic treatment.
The Fetal Lung
- Fluid VS air
- Fetal breathing
- Fetal ventilation and perfusion VS infant
The fetal lung is different from the adult lung in that the lungs in utero are filled with fluid, not air. The fetal lungs secret fluid which helps alveolar development. Pressure changes during birth expel the fluids and the fetal lung transitions to air filled.
Fetuses have irregular breathing movements in utero. These movements are shallow and do not cause fluid to move in and out of the lungs. They are thought to be conditioning the lungs for their job upon delivery. Breathing rate increases with higher levels of CO2 and decrease with hypoxia.
Fetal ventilation is nonexistent. The fetus is suspended in amniotic fluid which prevents the fluid filled lungs from exchanging gas. Perfusion and oxygenation are dependent on maternal mechanisms involving the placenta. These two separate aspects begin working together once the umbilical cord is cut and the infant is forced to begin breathing for itself.
Neonate
- Chest wall (advantages)
- Decreased lung compliance
- The neonate’s chest wall is highly complaint. This compliancy is advantageous during delivery to prevent damage to the mother and baby’s bodies. The chest wall compliance also helps inflate a compliant neonate lung.
- In situations where lung compliance is decreased, it requires increased force exerted from the diaphragm to fully inflate the lungs. Since the chest wall is complaint, the increased intrathoracic pressure exerted from the diaphragm can be seen as a chest wall and ribs spaces that are sunken in appearance during inspiration, these are known as retractions.
Retractions
- What are they?
- How do they appear in neonates and infants?
- Cause?
Retractions are abnormal inward movements of the chest wall during inspiration. They are caused by decreased lung compliance requiring increased diaphragmatic activity to overcome this. Retractions can be seen in the intercostals, substernal, or in the epigastric region.
Retractions can be exaggerated in neonates and infants due to chest wall compliance.
Retractions are often caused by airway obstructions or severe atelectasis.
Acute upper airway infections of children
- Croup
- Epiglottis
- Bronchiolitis
Croup
- What is it? Who is most commonly affected?
- Types
- Croup is an acute upper airway infection that most commonly affects infants and small children.
- Viral and spasmodic croup
Viral Croup
- S&S
- AKA (what is affected)
- Who is affected most often
- Most common pathogens
- Treatment
- How to know when the child needs more intensive care? What not to do?
- S&S - Viral croup is always preceded by a prodromal period where the patient experiences malaise, fatigue, and presents with a fever. Croup is characterized by inspiratory stridor (wheezing in the upper airways), hoarseness, and a barking cough. All these symptoms point toward a tight upper airway. Symptoms typically progress to mild stridor and slight dyspnea before starting to improve.
- AKA - viral croup is also known as acute laryngotracheobronchitis, this is because it affects the larynx, trachea, and bronchi.
- Children between the ages 3 months to 5 years old are most commonly affected.
- Viral croup is nonresponsive to antibiotics, expectorants, bronchodilating agents, and antihistamines. The best treatments for viral croup are moist air (humidifier). Exposure to cold air can often relieve symptoms of an airway spasm.
- Appearance of signs of respiratory distress such as cyanosis, retractions, progressive dyspnea, progressive stridor, and nasal flaring can indicate the need for emergent treatment. This presentation should not include manipulation of the pharynx (with tongue depressor).
Spasmodic Croup
- S&S
- How does it differ from viral croup?
- Treatment
S&S - same as viral croup with the exception of no fever, malaise, or fatigue.
Different - spasmodic croup is thought to have an allergen component. Typically worsens at night.
Treatment - humidification, or exposure to cold air to assist with airway spasms.
Where is the airway the narrowest during croup?
Subglottic regions
Seal like barking cough
Croup
Acute epiglottitis
- What is it?
- Most dangerous complications?
- S&S? Progression?
- Most common pathogen (vaccine)
- What should not be done when assessing these patients?
- Treatment
- Acute epiglottitis is a dramatic, potentially fatal inflammation and edema of the supraglottic area. This includes the epiglottis and the pharyngeal structures.
- Acute epiglottitis can progress to airway obstruction and asphyxiation. Is a sudden and quick moving presentation.
- The most common pathogen causing acute epiglottitis is H. Influenzae type B. Since the invention of a vaccine protecting the flu, other pathogens have increased frequency.
- S&S - tripod position, pale, toxic, lethargic, drooling, trouble swallowing, muffled voice, extreme anxiety. Progression can occur in hours and can present with signs of respiratory distress such as nasal flaring, retractions, cyanosis, stridor.
- NP should avoid pharyngeal manipulation and forcing the child to lay flat. Laying flat causes gravity to slide the epiglottis back further obstructing the airway.
- Treatment of acute epiglottitis depends on the severity. Antibiotic treatment should be matched with the offending pathogen. Intubation and/or tracheostomy may be necessary.
Sudden, quickly progressing upper airway infection. Presents with drooling, dyspnea, trouble swallowing, muffled voice, anxiety. Can progress to stridor, cyanosis, nasal flaring, and retractions.
Acute epiglottitis
Tonsillar Infections
- Causes
- S&S
- Why more common in children
- Complications
- Causes - children are at increased risk for tonsillitis and enlarged tonsils because their lymphatic system is maturing. They often have larger tonsils at baseline until later ages. Peritonsillar abscesses, tonsillitis
- Tonsillitis can be unilateral or bilateral. Peritonsillar abscess is typically seen as a unilateral presentation. Fever, sore throat, trouble swallowing, trismuis, drooling or pooling of saliva. Swollen lymph nodes.
- These tonsil infections can progress to life threatening events due to location of the inflammation and swelling associated with the infection or from rupture of the abscess leading to aspiration.
Bacterial Tracheitis
Most common potentially life-threatening UTRI in children. Airway edema and purulent secretion, mucosal sloughing.
Can be sudden onset or follow other respiratory infections such as croup
Acute Bronchiolitis
- Most common pathogen?
- Who is most commonly affected? How is it transmitted?
- What precedes this presentation?
- S&S?
- Treatment
- Acute bronchiolitis is a lower respiratory infection (small airways) that most commonly is caused by respiratory syncytial virus (RSV) in children.
- Children within their first two years of life are affected most commonly, with the peak incidence being between ages 3 and 6 months. Family members with minor respiratory illness are the most common mode of transmission.
- Acute bronchiolitis is usually preceded by symptoms of a mild respiratory illness such as stuffy nose, coughing, sneezing. These symptoms are often present in older family members before being passed to the baby.
- S&S - breathlessness, rapid, shallow breathing, wheezing, cough, retractions of lower ribs and sternum during inspiration if bad enough.
- Treatment - largely supportive. Nebulization can be used. Hydration.
Why does air trapping occur with bronchiolitis infections? How does this negatively affect the child?
Bronchiolitis infections (most commonly caused by RSV) are infections of the lower airway (small airways). This infection results in epithelial tissue necrosis which results in sloughing. The sloughing accumulates and restricts ventilation. Air has a easier time entering the lungs and a harder time exiting, resulting in the hyperinflation of the lungs.
Air that is trapped in the lungs is reabsorbed and results in local atelectasis.
What condition can RSV progress into?
Bronchiolitis and viral pneumonia
Atypical Pneumonia
- Cause? Who is affected more often?
“Walking pneumonia”
- Most common pathogen is Mycoplasma pneumoniae. This is the most common cause of CAP for school-aged children and young adults.
Asthma
- What is it?
- What triggers it?
- Hypersensitivity reaction
- S&S
- Asthma is a hypersensitivity reaction that is mediated by IgE. It normally is triggered by exposure to an allergen which results in an exaggerated immune response.
The exaggerated immune response causes inflammation of bronchial cells, mucosal edema, mucus plugging. and obstruction of airflow.
- S&S - cough, wheeze, SOB
Why is metabolic acidosis seen with hypoxemia?
Hypoxemia would trigger an increased RR as the chemoreceptors in the aortic arch and carotid sinus detect a drop in oxygen in the blood. This increased RR attempts to correct the drop, but a side effect of breathing faster is increased CO2 elimination. Increased CO2 elimination leads the body into a respiratory alkalosis which the kidneys attempt to compensate for by creating a metabolic acidosis.
Some conditions such as lactic acidosis can accumulate in conditions of hypoxemia. As cells are denied their required amounts of oxygen, they can switch to anaerobic metabolism which allows lactic acid to build, contributing to metabolic acidosis.
What are some signs and symptoms of Chronic hypoxemia?
- Increased ventilation (increased RR)
- Pulmonary vasoconstriction (to push more blood through quicker to increase tissue oxygenation)
- Increased RBC production (to allow more oxygen to be carried throughout the circulatory system)
Hypercapnia
- Defined as
- How can it affect the body?
Hypercapnia is increased levels of PCO2 measured on ABG. Normal values are 35-45mmHg.
Increased PCO2 in the body:
- Respiratory acidosis (decreased pH)
- Kidney function
- Nervous system (can cause CO2 narcosis, a condition where increased CO2 levels cause neurologic depression and can also cause respiratory depression, more commonly presents with confusion at lower levels)
- Cardiovascular - heart failure more commonly due to pulmonary hypertension caused by associated lung issues
Pleural effusion
Hemothorax
Pleuritis (aka)
Empyema
Chylothorax
- Pleural effusion - abnormal collection of fluid in the pleural cavity (blood, pus, chyle)
- Hemothorax - blood in the pleural space, can restrict the lungs ability to expand fully which can affect ventilation. Needs to be treated promptly.
- Pleuritis (aka pleurisy) - inflammation of the lung pleural. Painful and associated with pneumonia and other conditions. Heard through rub type sound.
- Empyema - collection of pus in the pleural space. Can cause sepsis.
- Chylothorax - collection of milky fluid (normally found in the lymphatic system, contains lipids and fat) collects in the pleural space. Can restrict lung function.
Pneumothorax
- Spontaneous
- Traumatic
- Tension
Condition where air is allowed to accumulate in the pleural space. The pleural space is normally filled with a small amount of fluid that functions to reduce friction with lung movement. This air entering the pleural space disrupts pressures in the lung causes the affected lung to collapse. If the air continues to enter the pleural cavity without means of escape, this can progressively increase the pressure and can displace surrounding structures, such as the trachea. This is known as tension pneumothorax.
- Spontaneous - occurs randomly. Happens more often in tall, thin young men
- Traumatic - puncture wound pokes a hole in the chest wall and into the pleural cavity allowing air to enter the normally negative pressure area.
- Tension - air becomes trapped and continues to enter. Intrapleural pressure exceeds atmospheric. Will see a midline shift of the trachea, JVD, resp distress.
Primary VS Secondary pneumothorax
- Why are secondary pneumothoracies more dangerous than primary ones?
- What diseases are associated with secondary pneumothorax? Describe these diseases
Primary - can occur in otherwise healthy people. Lung collapse, usually from the bursts of a bleb on the lung surface. Tall, young, males are most commonly affected.
Secondary - occur in individuals with underlying lung dysfunction. This underlying lung dysfunction reduces the individuals ability to compensate and can be a life threatening event that an otherwise healthy individual would be able to overcome.
Common causes of secondary pneumothoraxes are chronic lung diseases that result in air trapping. Emphysema is the most common. Asthma, COPD, cystic fibrosis, sarcoidosis, and carcinomas can result in this air trapping that place increased pressures on the lung which results in the rupture of the pleural cavity and allowance of air to enter the normally negative pressurized area.
Autonomic nervous system control over smooth muscle in the bronchials
- Parasympathetic - vagus nerve activation can stimulate bronchoconstriction
- Sympathetic - B2-adrenergic receptors stimulate bronchodilation. Think - during emergencies someone would need more air so larger airways would provide
COPD
- What physiologic changes does it cause to the body?
COPD causes:
- Inflammation and fibrosis to bronchial walls - this reduces airway passages. This contributes to wheezing and air trapping that are characteristic of this condition.
- Hypertrophy of submucosal glands and hypersecretion of mucus - this further exacerbates the narrowed airways and air trapping seen in the disease. Patients constantly struggle with thick tenacious secretions.
- Loss of elastic lung fibers - the lungs become less compliant. They have decreased stretch. This leads to a decreased expiratory flow rate which leads to air trapping and hyperinflation.
- Alveolar destruction - decreases surface area for gas exchange
How do COPD patient differ in appearance?
- Barrel chest - air trapping and hyperinflation of the lungs over time leads to increased lung size and a change in the chest to accommodate. The normal A-P ratio is altered from 1/2 to 1/1.
What are the two classifications of COPD?
Describe each. Who are they commonly found in?
- Chronic bronchitis - airway obstruction of the major and small airways. Most common in middle aged men who smoke. Excessive mucus production and chronic cough.
- Emphysema - loss of lung elasticity and abnormal enlargement of the airspaces. Destruction of the alveolar walls and capillary beds. Leads to decreased oxygenation and SOB.
Cystic fibrosis affects on the respiratory system
CF presents with excess mucus production that is unusually thick, tenacious. This mucus can obstruct airways and lead to air trapping, lung hyperinflation. Seen more in children.
What is the major difference in lung volumes between obstructive and restrictive pulmonary diseases?
Obstructive pulmonary diseases have normal or hyperinflated lung volumes due to difficulties fully exhaling leading to air trapping. The issue lies with he airways.
Restrictive lung disease results in a noncompliant and fibrotic lung tissue which reduces lung volumes.
What are interstitial lung disease? What are they also known as? How do they present? What are characteristic signs and symptoms seen with these diseases?
Interstitial lung diseases are a group of respiratory illnesses that target the collagen and connective tissue that support the respiratory system. They result in fibrotic, noncompliant lungs. ILD illness cause those affected to take shallow, small breaths. They are easily fatigued by exercise. Maintain their minute volume through rapid shallow breathing. Low lung volumes.
What is respiratory failure?
What are the two types of respiratory failure?
Respiratory failure - hypoxemia or hypercapnia due to heart, lung, or both not working.
- Hypoxemic resp failure due to failure of gas exchange at the lung
- Hypercapnic/hypoxemic failure due to ventilatory failure
Hypoxemic Respiratory Failure
- Layman’s
- Examples
Failure of the lungs to perform gas exchange adequately resulting in hypoxemia.
Patient is ventilating (breathing oxygen in and CO2 out) but exchange of these gases is reduced.
- COPD, pneumonia, ILD
Hypercapnic/Hypoxemic Respiratory Failure
- Examples
What are some causes of ILD?
- Environmental/ Occupational irritants (coal, soil, dust, asbestosis). Drugs induced (chemo, amio, others). Immunologic (sarcodosis).
