MG Respiratory 1 Lecture ppt Flashcards
1
Q
Atelectasis
A
- Closure or collapse of alveoli or possibly filled with alveolar fluid
- One of the most common breathing (respiratory) complications after surgery.
- Acute or chronic
- Clinical Manifestations:
- Insidious, increasing dyspnea, cough, and sputum production
- Acute: tachycardia, tachypnea, pleural pain, and central cyanosis if large areas of the lung are
affected - Most common is acute atelectasis, occurring in the postoperative setting
- Chronic: similar to acute, pulmonary infection may be present
2
Q
Common Risk Factors. atelectasis
A
- Older age
- Bedrest w/o frequent changes in position
- Recent surgery
- Lung disease (COPD, asthma, etc.)
3
Q
Assessment and Diagnosis Atelectasis
A
- Characterized by increased WOB and hypoxemia
- Decreased breath sounds and crackles over the affected area
- Chest x-ray may suggest atelectasis before clinical symptoms appear
- Pulse oximetry (SpO 2 ) may be less than 90%
4
Q
Management. Atelectasis
A
Management
* Goal is to improve ventilation and remove secretions
* First line measures:
* Frequent turning, early ambulation, lung volume expansion maneuvers and coughing
* Multidisciplinary: ICOUGH (chart 19-3)
* CPT
* Thoracentesis to relieve compression
* Endotracheal intubation and mechanical ventilation
5
Q
Oxygen Therapy
A
- Administering of oxygen can decrease WOB and reduce stress on the myocardium
- Hypoxemia: decrease in the arterial oxygen tension in the blood
- Hypoxia: decrease in oxygen supply to the tissues and cells that can also be caused by problems outside
the respiratory system - Severe hypoxia can be life threatening
- More on oxygen delivery next week in COPD lecture
6
Q
Postural Drainage
A
- Allows force of gravity to assist in removal of bronchial secretions
- Secretions drain from the affected bronchioles into the bronchi and trachea and are removed by coughing
or suctioning - Used to prevent or relieve bronchial obstruction caused by accumulation of secretions
- Because the patient usually sits in an upright position, secretions are likely to accumulate in the lower parts
of the lungs
7
Q
Influenza
A
- Highly contagious respiratory illness caused by a virus
- Flu season
- September to April peaking in November
- 490k people hospitalized
- 61k deaths annually (CDC, 2017-2018)
10
8
Q
Influenza Etiology & pathophysiology
A
Influenza Etiology & pathophysiology
* Virus mutates to allowing it to infect different species
* Classified into three serotypes (A,B,C)
* Only A & B cause significant illness in humans
* Influenza A
* Most common
* Most virulent
* Can spread from animals to humans
* Known to cause pandemics
* 75% of confirmed seasonal infections
9
Q
Influenza Etiology & pathophysiology
* Influenza A
A
- Influenza A
- Subtyped
- (H) Hemagglutinin
- Allows virus to enter cell
- (N) Neuraminidase
- Facilities cell to cell transmission
- Influenza named based on these subtypes
- Examples are:
- H1N1 (swine flu), H5N1 (bird flu)
10
Q
Influenza Etiology & pathophysiology
* Influenza B
A
- Similar to type A
- Only spread from human to human
- Can cause seasonal outbreaks
- Can be transferred throughout year
- Influenza C
- Mildest version
11
Q
Influenza Transmission
A
- Person to person through
- Droplets and inhalation of particles
- Incubation period
- 1-4 days
- Peak transmission period
- One day before symptoms appear
- Continues for 5-7 days after first appearing ill
12
Q
Influenza Clinical Manifestations
A
- Onset abrupt
- Fever / chills
- Myalgia (generalized muscle/joint aches & pains)
- HA (headache)
- Sore throat
- Fatigue
- Symptoms typically subside within 7 days
13
Q
Influenza Diagnostics
A
- Based on health history
- Viral cultures
- reverse transcription polymerase chain reaction (RT-PCR),
- Results may take 1-2 days; can identify which strain present
- Rapid influenza diagnostic test
- Available from PCP, outpatient facilities
- Results in 10-15 minutes
- Useful to differentiate flu from other infections
- Diagnosis missed or false positive possible (50-70% correct)
- Followed up with RT-PCR
14
Q
Influenza Treatment
A
- Prevention best strategy
- Quit smoking
- Stay home if flu-like symptoms
- Frequent hand washing
- Keep hands away from face
- Avoid close contact with infected persons
- Influenza vaccine
- Best received before exposure
- Trivalent Inactivated Influenza vaccine (TIV)
- Administered by intramuscular injection
- Approved for
- Anyone over 6 months of age
- Pregnant women
- Immunocompromised persons
- Residents of nursing homes
- Common side effects
- Fatigue, low grade fever, headache
- Injection site reactions (pain, swelling, redness)
- Live attenuated Influenza vaccine (LSIV)
- Administered nasally
- Healthy persons age 2 - 49 y/o
- Not given to
- Persons known to be immunocompromised
- Children/adolescents receiving ASA or salicylates
- Common side effects
- Runny nose/congestion
- Sore throat in adults
- Fever in children (2-6 y/o)
15
Q
Influenza Complications
A
- Pneumonia (PNA)
- Dyspnea or crackles early sign of pulmonary complication
- Ear or sinus infection
- Dehydration (particularly in older adults)
16
Q
Pneumonia
A
- Acute infection of lung parenchyma
- Associated with significant morbidity and mortality rates
- Pneumonia and influenza are 8th leading cause of death from infectious diseases in the
U.S. - 880,000 deaths from pneumonia in children under the age of five in 2016.
- Most were less than 2 years of age (American Thoracic Society)
17
Q
Etiology Pneumonia
A
- Mucociliary mechanism impaired by:
- Pollution
- Cigarette smoking
- Upper respiratory infections
- Tracheal intubation
- Aging
- Chronic diseases suppress the immune system
18
Q
PNA Risk factors
A
- Smoker, ETOH
- Immunosuppressed (AIDS)
- HF, COPD, DM, flu
- Prolonged immobility
- NGT, OGT, or ETT placement
- Older
- Poor HOB
- Lack of vaccination (>65 or >19 w/ weak immune systems)
19
Q
Types of Pneumonia (Chart 19-4)
A
- Classified by type:
- Clinical classification:
- Community-acquired (CAP)
- Hospital-acquired (HAP)(HCAP)
- Ventilator-associated (VAP)
- Aspiration
- COVID PNA
- Not covered this semester:
- Multidrug-resistant (MDR), Necrotizing Pneumonia, Opportunistic Pneumonia
20
Q
Types of Pneumonia: Community-Acquired Pneumonia (CAP)
A
- Occurs in patients who have not been:
- Hospitalized or
- Resided in a long-term care facility
- within 14 days of the onset of symptoms
- May be treated at home or hospitalized dependent on patient condition
- Empiric antibiotic therapy started ASAP
21
Q
Types of Pneumonia: Hospital-Acquired Pneumonia (HAP)
A
- Occurs 48 hours or longer after admission
- Not present at time of admission
- VAP: Occurs more than 48 hours after endotracheal intubation
- Associated with
- longer hospital stays
- increased costs
- sicker patients
- increased risk of morbidity and mortality
22
Q
Types of Pneumonia: Aspiration
A
- Aspiration Pneumonia
- Results from abnormal entry of secretions into lower airway
- Major risk factors:
- Decreased level of consciousness
- s/p CVA
- Difficulty swallowing
- Insertion of NGT with or without tube feeding
23
Q
Clinical Manifestations of Pneumonia
A
- Varies depending on type, causal organism, and presence of underlying disease
- Streptococcal: Sudden onset of chills, fever, pleuritic chest pain, tachypnea, and
respiratory distress - Viral, mycoplasma, or Legionella: relative bradycardia
- Common in Live Engagement
24
Q
Diagnostics Pneumonia
A
- H&P, Focused physical examination
- Chest x-ray (CXR)
- CBC with differential
- WBC usually greater than 15,000 with presence of bands
- Sputum analysis
- Culture and Gram stain to identify the organism
- Ideally sputum obtained before beginning ABX but do not delay Tx
- Bronchoscopy may be used for acute severe infection
25
Q
Further Diagnostics
A
Further Diagnostics
* For those not responding to treatment
* Blood cultures
* Thoracentesis*
* Bronchoscopy* (with/without washings)
* Biologic markers to guide clinical decisions:
* C-reactive protein (CRP)
* Procalcitonin (Viral or Bacterial
* *may be used to diagnose or treat
26
Q
CURB-65
A
CURB-65
* Physician may use the CURB-65 tool to aid in decision to hospitalize. Each item is worth
one point
* Confusion
* BUN > 19 mg/dL (> 7 mmol/L)
* Respiratory Rate ≥ 30
* Systolic BP < 90 mmHg or Diastolic BP ≤ 60 mmHg
* Age ≥ 65
27
Q
Complications
A
- Atelectasis
- Pleurisy
- inflammation of the pleura
- Pleural effusion
- fluid in the pleural space
- Pneumothorax
- air collects in the pleura space, causing the lungs to collapse
28
Q
Complications (con’t)
A
- Meningitis
- Pt may be disoriented, confused, drowsy
- Acute respiratory failure
- Leading cause of death in severe PNA
- Lungs can no longer exchange O 2 for CO 2
- Sepsis/septic shock
- Occurs when bacteria within alveoli enter the bloodstream may lead to sepsis
- Rare Complications
- Lung abscess, empyema
29
Q
Interprofessional Care
A
- Prompt treatment with antibiotics is a priority over other treatments
- Initial therapy is empiric
- Based on likely infecting organism and risk factors for MDR organisms
- Varies with local patterns of antibiotic resistance
- Supportive care in addition to Abx
- Oxygen, analgesics, antipyretics
- Individualize rest and activity
- No definitive treatment for majority of viral pneumonias
- Self-limiting within 3-4 days
30
Q
Interprofessional Care
A
- Supportive care in addition to Abx
- Oxygen for hypoxemia
- Analgesics for chest pain
- Antipyretics
- Individualize rest and activity
- No definitive treatment for majority of viral pneumonias
- Self-limiting within 3-4 days
- Antivirals for influenza pneumonia
31
Q
Drug Therapy
A
- Start with empiric therapy
- Based on likely infecting organism and risk factors for MDR organisms
- Varies with local patterns of antibiotic resistance
- Should see improvement in 3-5 days
- Start with IV Abx and then switch to oral therapy as soon as patient stable
32
Q
Ambulatory Care
A
- Patient teaching for home care
- Emphasize need to take full course of medication(s)
- Drug-drug and drug-food interactions
- Adequate rest
- Adequate hydration
- Avoid alcohol and smoking
- Cool mist humidifier
- Chest x-ray, vaccinations
33
Q
Tracheostomy
A
- Surgically created stoma (opening) used to
- Establish a patent airway
- Bypass an airway obstruction
- Facilitate secretion removal
- Permit long-term mechanical ventilation
- Facilitate weaning from mechanical ventilation
- Complication is air bypasses nose and throat so loss of
humidification and filtration results
34
Q
Advantages of Tracheostomy vs. Endotracheal Tube
A
- Easier to keep clean
- Better oral and bronchial hygiene
- Patient comfort increased
- Less risk of long-term damage to vocal cords
35
Q
Indications for Tracheostomy
A
- Laryngeal Cancer
- Prolonged ventilator dependence
- Upper airway obstruction
- Neuromuscular Disease
36
Q
Possible Swallowing Dysfunction
A
- Inflated cuff
- Interferes with normal function of muscles used to swallow
- Clinical assessment for swallowing ability and aspiration risk
- Diet
- May require soft food initially, ADAT
- If no risk for aspiration, leave cuff deflated or replace with a cuffless tube
- Primary care provider decision
37
Q
Removal of Tracheostomy Tube
A
- When patient no longer requires ventilatory support, can breathe spontaneously, and protect own
airway - effectively coughing up secretions, swallow
- Use of cuffless or fenestrated tracheostomy tube in decreasing sizes
- After tube removed, an occlusive dressing is placed over the stoma
- self heals over next several days or weeks
- NPO until swallowing evaluated
- Encourage patient to T,C, DB q 1 hour
- IS use
38
Q
Tuberculosis (TB)
A
- Infectious disease caused by Mycobacterium tuberculosis
- Lungs most commonly infected
- Aerophilic (oxygen-loving) – causes affinity for lungs
- 1/3 of world’s population has TB
- 10 million get TB each year; 1.6 million die from TB
- Leading cause of death in patients with HIV/AIDs
- Prevalence is decreasing in the United States
39
Q
TB Risk Factors
A
- Homeless
- Residents of inner-city neighborhoods
- Foreign-born persons
- Living or working in institutions (includes health care workers)
- IV injecting drug users
- Poverty, poor access to health care
- Immunosuppression (HIV, cancer, organ transplant, high dose steroids)
40
Q
Clinical Manifestations
A
- LTBI (Latent tuberculosis infection)
- Asymptomatic
- Pulmonary TB
- Takes 2-3 weeks to develop symptoms
- Initial dry cough that becomes productive
- Constitutional symptoms (fatigue, malaise, anorexia, weight loss, low-grade fever,
night sweats) - Dyspnea and hemoptysis late symptoms
41
Q
Clinical Manifestations
A
- Cough becomes frequent
- Low grade fever
- Night sweats
- Fatigue
- Unexplained weight loss
- Hemoptysis not common (advanced disease)
- Dyspnea is unusual
42
Q
Diagnostic Studies
A
- Tuberculin Skin Test (TST) aka: Mantoux test
- Purified protein derivative (PPD) injected intradermally
- Assess for induration in 48 – 72 hours
- Presence of induration (not redness) at injection site indicates development of
antibodies secondary to exposure to TB - Two-step testing recommended for health care workers getting repeated testing and
those with decreased response to allergens - Patients who have received the BCG vaccine will have a positive Mantoux test
43
Q
Other Diagnostic Studies
A
- Interferon-γ gamma release assays (IGRAs)
- T-SPOT
- Chest x-ray
- May show lesions in upper lobes
- Bacteriologic studies
- Required for diagnosis
- Consecutive sputum samples obtained on 3 different days
44
Q
Interprofessional Care
A
- Hospitalization not necessary for most patients
- Infectious for first 2 weeks after starting treatment if sputum +
- Drug therapy used to prevent or treat active disease
- Need to monitor compliance
45
Q
Discharge to home, high risk individuals
A
- Many tuberculosis (TB) patients are never hospitalized. The greatest risk of transmission
occurs prior to initiation of treatment. - If there is a likelihood of transmission to other or severity is high, it may be necessary to
keep patient hospitalized until sputum is negative - Requires three consecutive negative sputum smears (three different days)
46
Q
Criteria for discharge to home, with no high risk individuals in the home:
A
- The patient has been started on an appropriate multiple drug regimen and is tolerating medications
- The patient is medically stable and able to care for self.
- The patient understands and can comply with home isolation (i.e., will not leave home or have
unexposed visitors without wearing a mask, and has adequate support for meals and other essentials of
daily living). - A plan for ongoing follow up and treatment has been established, directly observed therapy (DOT)
arranged, and discharge approval obtained from local health department.
47
Q
Drug Therapy
A
- Active disease
- Treatment is aggressive
- Two phases of treatment for newly diagnosed
- Initial 8 weeks w/ continuation (16-42 weeks if continued positive)
- Four-drug regimen (be familiar with common side effects & NSG considerations)
- Isoniazid
- Rifampin
- Pyrazinamide
- Ethambutol
48
Q
Drug Therapy
A
- Patients should be taught about side effects and when to seek medical attention
- Liver function should be monitored (AST & ALT)
- Alternatives are available for those who develop a toxic reaction to primary drugs
- People are considered noninfectious after 2 to 3 weeks of continuous medication
therapy
49
Q
Drug Therapy
A
- Directly observed therapy (DOT)
- Noncompliance is major factor in multidrug resistance and treatment failures
- Requires watching patient swallow drugs
- Preferred strategy to ensure adherence
- May be administered by public health nurses at clinic site
50
Q
Drug Therapy
* Latent TB infection
A
- Latent TB infection
- Health care workers who develop a positive TB test
- Usually treated with Isoniazid for 6 to 9 months
- Alternative 3-month regimen of Isoniazid and rifapentine OR 4 months of rifampin
