Lower Respiratory Disorders

Question 1

Pulmonary Embolism (PE)

Answer 1

Emboli; mobile clots that travel through circulatory system
Blockage in a pulmonary artery by an embolic thrombus (fat or air embolus, or tissue from a tumor)
Travel to ever-smaller blood vessels until it lodges & obstructs perfusion of the alveoli
More than 90% arise from deep vein thrombosis (DVT) of the legs
Usually affects lower lobes d/t high volume of blood flow
10% of patients die within the first hour
Treatment with anticoagulants reduces mortality to less than 5%

Question 2

PE Risk Factors

Answer 2

Immobility or reduced mobility
Surgery in the last 3 months
History of DVT
Malignancy
Obesity
Oral contraceptives & hormone therapy
Heavy cigarette smoking
Prolonged air travel
Heart failure
Pregnancy
Clotting disorders

Question 3

PE Clinical Manifestations

Answer 3

Varied & nonspecific, making it difficulty to diagnose
Dyspnea
Hypoxemia (if severe, change in mental status)
Tachypnea
Cough
Chest pain
Hemoptysis
Crackles and/or wheezing
Tachycardia
Fever
Syncope
Massive PE = hypotension & shock

Complications
Pulmonary Infarction
Death of lung tissue
May become infected & abscess may develop

Pulmonary Hypertension
from a massive or recurrent PE
Results from hypoxemia or damage to 50% of area’s normal pulmonary bed

Question 4

PE Diagnostic Studies

Answer 4

Find under-lying cause; DVT or AFIB?)

Spiral (helical) CT scan w/ IV contrast
Most frequently used to diagnose PE
Ventilation-perfusion (V/Q) lung scan
Used for those allergic to IV contrast
Mismatch of perfusion & ventilation indicates PE

EKG monitoring
Labs:
CBC
BMP
ABG’s
PTT
PT / INR
Troponin
D-dimer
Measures fibrin fragments
Not always accurate
Chest X-Ray
Venous ultrasound
Pulmonary angiography

Question 5

PE Collaborative Care

Answer 5

Immediate treatment as soon as PE suspected
Bedrest; Semi-Fowler’s position
02 by NC or mask
Cardiac monitoring, VS, 02 level, ABG’s, breath sounds
Fibrinolytic agent
IV Heparin drip (RN management by protocol)
Lovenox (Low-molecular-weight Heparin)
Warfarin (Coumadin)
Monitor PTT and/or PT/INR levels
Opioids for pain relief
Medications PRN anxiety
Inferior Vena Cava filter
Inserted via femoral vein, placed at level of diaphragm
Pulmonary embolectomy

Patient Teaching
Risk factors
Long-term anticoagulant therapy
Frequent blood draws for PT/INR monitoring
Coumadin adjustments
Dietary considerations

Question 6

Pneumonia

Answer 6

Acute infection of lung parenchyma
Gram-negative bacilli
8th leading cause of death in 2018
Impacted by discovery of Sulfa & Penicillin
Despite new anti-microbial agents, morbidity & mortality still significant

Risk Factors
Immunosuppressive diseases or debilitating illness
Increased risk of aspiration
Decreased cough & epiglottal reflexes, tube feedings
Impaired muco-ciliary mechanism
Pollution
Smoking
Upper respiratory infections
Tracheal intubation
Age >65 years
Malnutrition
Inhalation of microbes (Mycoplasma/fungus)
Spread from primary infection elsewhere in body

Question 7

Opportunistic Pneumonia

Answer 7

Altered immune system
Severe protein-calorie malnutrition
HIV / AIDS
Radiation therapy
Chemotherapy
Long-term corticosteroid therapy
Pneumocystis jiroveci (fungus)– needs a human host
Cytomegalovirus (CMV)

Question 8

Community-Acquired Pneumonia (CAP)

Answer 8

7th leading cause of death for those over 65 years old
Pre-hospital onset or within first 2-days of admit
Highest incidence in winter
Smoking important risk factor
May present only with dyspnea & fever while lung tissue is necrotized
Viral manifestations vary:
Fever, chills
Dry, non-productive cough
Extra-pulmonary symptoms

Question 9

Hospital-Acquired Pneumonia (HAP)

Answer 9

48-hours or more after admission
Early (5-days or less post admission)
Late (more than 5-days post admission)
Nosocomial infection with highest mortality
Pseudomonas
Enterobacter
S. Aureus
S. Pneumoniae

Risk factors:
Immunosuppression
General debility
ET Tube (VAP)
Fungal/aspiration pneumonia
Loss of consciousness
Gag/cough reflexes
Tube feedings

Question 10

CAP

Answer 10

Gradual symptom onset
Dry cough
Headache
Malaise / fatigue
Sore throat
N/V/D (S. aureus)

Question 11

HAP

Answer 11

Sudden onset symptoms
Fever
Chills
Productive cough
Purulent sputum
Pleuritic chest pain
Confusion or stupor in older or debilitated patient

Question 12

Clinical Manifestations CAP/HAP

Answer 12

Cough – non-productive or productive – green, yellow, bloody
Fever/chills/shaking
Dyspnea
Tachypnea
Pleuritic chest pain
May initially appear as influenza, then respiratory sypmtoms
Confusion or stupor r/t hypoxia
Hypothermia (in elderly)
Diaphoresis, anorexia, fatigue, myalgia, headache, abd pain
Rhonchi and Crackles
Dullness to percussion over affected area

Question 13

Diagnostic Studies CAP/HAP

Answer 13

H & P
Chest X-Ray
Vital Signs - Sp02 and ABG’s
CBC, CMP, Blood Cultures
Sputum Culture – prior to Antibiotic therapy

Question 14

Collaborative Therapy
CAP/HAP

Answer 14

Antibiotic therapy: Multi-drug resistant pneumonia is a major problem
Increased fluid intake (3L/day)
Limit activity and rest
Antipyretics
Analgesics
02 therapy
Influenza & Pneumonia Vaccination - pneumovax

Question 15

Complications from Pneumonia

Answer 15

Pleurisy or pleural effusion
Atelectasis
Persistent infection
Lung abscess
Empyema
Pericarditis
Endocarditis
Arthritis
Meningitis
Pneumothorax
Sepsis
Respiratory failure

Question 16

Nursing Assessment Pneumonia

Answer 16

History
Lung cancer
COPD
Diabetes mellitus
Debilitating disease
Malnutrition
AIDS
Use of antibiotics, corticosteroids, chemotherapy, immunosuppressants
Recent abdominal or thoracic surgery
Smoking, alcoholism, respiratory infections
Prolonged bed rest

Physical Assessment
Dyspnea
Nasal congestion
Pain with breathing
Sore throat
Muscle aches
Fever
Restlessness or lethargy
Splinting affected area
Tachypnea
Tachycardia
Asymmetric chest movements
Use of accessory muscles
Crackles
Green or yellow sputum

Question 17

Nursing Considerations for Pneumonia

Answer 17

Tachycardia
Changes in mental status
Leukocytosis
Abnormal ABGs
Pleural effusion
Pneumothorax on x-ray

Question 18

Pneumonia: Patient Teaching

Answer 18

Nutrition, hygiene, rest, regular exercise to maintain natural resistance
Prompt treatment of upper respiratory infections
Offer / encourage influenza & pneumococcal vaccines – New: COVID vaccine
Reposition every 2-hours
Assist with eating, drinking & taking medications
Emphasize need to finish course of antibiotics
Teach drug-drug interactions
TCDB / “Pulmonary toilet”
Strict asepsis, hand-washing

Question 19

Lung Cancer Facts

Answer 19

Leading cause of cancer-related deaths in U.S.
Estimated 221,000 new cases diagnosed annually
High mortality, low cure rate – although treatment advancing
Early detection is important

Risk factors
Smoking – 80-90%
Pollution
Radiation
Occupational
Asbestos
Coal dust
Nickel
Uranium
Chromium
Formaldehyde
Arsenic

Question 20

Types of Lung Cancer

Answer 20

Non-small cell (NSCLC) 80%
Squamous cell
Large bronchi
Slow speed- takes 8 to 10 yrs for a tumor to reach 1 cm
Adenocarcinoma
Alveoli
Moderate speed
Most common in nonsomokers
Large cell
Rapid speed
Highly metastatic

Small cell (SCLC) 20%
Larger airways
Most malignant
Early metastasis
Associated endocrine disorders
More sensitive to chemo
Poorer prognosis
Associated with paraneoplastic Syndrome

Question 21

Diagnostic & Therapy

Answer 21

Chest X-Ray – 5% incidentally find cancer
Sputum cytology
Bronchoscopy
CT scan, MRI, PET, VATS,
Mediastinoscopy
Trans-bronchial or percutaneous fine-needle aspiration
Surgery
Radiation and/or Chemotherapy

Question 22

Clinical Manifestations

Answer 22

Early
Persistent cough
Blood tinged sputum
Dyspnea or wheezing
Chest pain
Later
Anorexia
Fatigue
Weight loss
Nausea / vomiting
Hoarseness
Palpable lymph nodes in neck or axillae

Question 23

Staging & Signs of Metastasis

Answer 23

Hoarseness
Recurrent laryngeal nerve
Dysphagia
Esophageal compression
Superior vena cava syndrome
Venous obstruction
Shortness of breath
Facial, arm, trunk swelling
Distended neck veins
Chest pain
Venous stasis

Mediastinal Lymph Node Involvement
Vocal cord paralysis
Dysphagia
Diaphragmatic paralysis
Phrenic nerve compression
Vena cava compression
Pleural effusion

Question 24

Para-neoplastic Syndrome

Answer 24

Immune response against tumor mediated by humoral factors
Hormones & cytokines excreted by tumor cells
Hypercalcemia
Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
Dilutional hyponatremia
Anemia
Leukocytosis
Hypercoagulation disorders
Neurologic syndromes

Question 25

Treatment of Lung Cancer

Answer 25

Radiation therapy
Chemotherapy- Primary treatment for SCLC and adjuvant to surgery in NSCLC
Surgery
Segmental, “wedge” resection
Lobectomy
Pneumonectomy
Immunotherapy – Can be used in people with NSCLC whose cancer starts growing again after chemo

Pneumonectomy
Chest tubes may, or may not be placed
If placed, it is clamped & only released by surgeon to adjust volume of sero-sanguinous fluid allowed to fill space
Daily CXR
Position patient operative-side DOWN
Pain management

Question 26

Pneumothorax

Answer 26

Caused by air entering pleural cavity
Positive pressure in pleural space causes lung to partially or fully collapse
Increased air in pleural space equals reduced lung volume
Open: opening in chest wall
Penetrating trauma—sucking chest wound
Closed: no external wound
Suspect pneumothorax with chest wall trauma

Manifestations
Small pneumothorax
Mild tachycardia and dyspnea
Large pneumothorax
Respiratory distress
Absent breath sounds over affected area
Diagnostic Study: Chest x-ray

Question 27

Types of Pneumothoraces

Answer 27

Spontaneous—rupture of blebs
Can occur in healthy or chronically ill persons (COPD, asthma, cystic fibrosis, pneumonia)
Risk factors: Tall, thin, male, family history, or previous spontaneous pneumothorax
Iatrogenic —medical procedures
Biopsies, subclavian catheter insertion, ventilator, esophageal trauma
Tension pneumothorax
Accumulation of air in pleural space that cannot escape results in increased intrapleural pressure
Causes mediastinal shift and hemodynamic instability: reduced venous return and reduced cardiac output
Medical emergency – may be fatal if not corrected

Question 28

Types of Pneumothoraces

Answer 28

Spontaneous—rupture of blebs
Can occur in healthy or chronically ill persons (COPD, asthma, cystic fibrosis, pneumonia)
Risk factors: Tall, thin, male, family history, or previous spontaneous pneumothorax
Iatrogenic —medical procedures
Biopsies, subclavian catheter insertion, ventilator, esophageal trauma
Tension pneumothorax
Accumulation of air in pleural space that cannot escape results in increased intrapleural pressure
Causes mediastinal shift and hemodynamic instability: reduced venous return and reduced cardiac output
Medical emergency – may be fatal if not corrected

Question 29

Hemothorax and Chylothorax

Answer 29

Hemothorax
Blood in pleural space
Treat with chest tube
Hemopneumothorax
Blood and air in pleural space
Chylothorax
Lymphatic fluid in pleural space
Treat conservatively or with Octreotide
Refractory options: surgery or pleurodesis

Question 30

Interprofessional Care

Answer 30

Dependent on severity, underlying cause and hemodynamic stability
Emergency treatment—Cover wound with dressing secured on 3 sides
If impaled object in place, stabilize it with a bulky dressing but do not pull it out
Treatments
Chest tubes with water-seal drainage
Other: partial pleurectomy, stapling, or pleurodesis
Tension pneumothorax
Needle decompression— immediate
Chest tube and water-seal drainage

Inspiration: pulls dressing against wound so air cannot enter pleural space
Expiration: dressing pushes out and air escapes

Question 31

Chest Tubes and Pleural Drainage

Answer 31

Chest tubes
Drain pleural space
Reestablish negative pressure
Allow lung to expand
Small: air Medium: fluid Large: blood

Question 32

Chest Tube

Answer 32

Collection device for fluid, air, or blood from chest cavity
Three basic compartments
1st compartment or collection chamber
Fluid stays in; air vents to 2nd compartment
2nd compartment or water-seal chamber
Contains 2 cm of water; acts as one-way valve; air goes in, bubbles out, but can’t go back to patient
3rd compartment or suction control chamber
Uses column of water to control suction from regulator

Bubbling in water-seal chamber
Brisk at first, eventually disappears as lung expands
Intermittent with exhalation, coughing, or sneezing
Tidaling in water-seal chamber
Fluctuation of water with pressure changes during respiration
Disappears as lung re-expands
If stops suddenly, check for occlusion
Suction control chamber
Wet suction
Amount of water in chamber (20 cm) controls suction
Excess suction from source vented
Usual suction order = −20 cm H2O
Adjust suction until gentle bubbling in third chamber
Dry suction—no water (less noise)
Dial regulator to pressure; visual alert

Question 33

Nursing Management: Chest Drainage

Answer 33

Drainage system
Keep tubing loosely coiled
Keep connections tight; taped
Observe: tidaling, bubbling, air leak, fluid levels
Patient’s clinical status
Assess:
Vital signs, lung sounds, pain
Drainage amount
Drainage site infection
Subcutaneous emphysema
Encourage:
Deep breathing/Incentive spirometry
Range-of-motion exercises

Chest drainage
Keep below chest
Mark and measure drainage
Report greater than 200 mL/hr in first hour and 100 mL/hr thereafter; replace unit when full
Avoid overturning unit
Breakage of unit
Place distal end of chest tube in 2 cm water in sterile container; replace unit
No milking or stripping chest tubes

Dry suction chest drainage – Most common type
Wet suction chest drainage
Monitor:
Water levels
Suction at—20 cm H2O
Gentle bubbling
Chest tube dressings
Change according to agency policy and procedure
Petroleum gauze
Aseptic technique
Monitor for infection
Document
Clamping chest tubes
Not advocated during transport or disconnection due to risk for tension pneumothorax
May clamp briefly to change drainage unit

Question 34

Removal of Chest Tubes

Answer 34

When lungs reexpanded and drainage minimal
Premedicate prior to removal
Valsalva maneuver during removal
Apply occlusive dressing
Chest x-ray
Monitor for respiratory distress

Question 35

Abnormal Lung Sounds

Answer 35

Crackles (rales)
Snorous Wheezes (rhonchi – low pitched)
Sibilant Wheezes (high pitched)
Stridor