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Block II Lecture Exam 2 > MG Respiratory 1 Lecture ppt > Flashcards

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
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2
Q

Common Risk Factors. atelectasis

A
  • Older age
  • Bedrest w/o frequent changes in position
  • Recent surgery
  • Lung disease (COPD, asthma, etc.)
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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%
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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

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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
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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
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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
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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

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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)
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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
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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
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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
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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
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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)
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15
Q

Influenza Complications

A
  • Pneumonia (PNA)
  • Dyspnea or crackles early sign of pulmonary complication
  • Ear or sinus infection
  • Dehydration (particularly in older adults)
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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)
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17
Q

Etiology Pneumonia

A
  • Mucociliary mechanism impaired by:
  • Pollution
  • Cigarette smoking
  • Upper respiratory infections
  • Tracheal intubation
  • Aging
  • Chronic diseases suppress the immune system
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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)
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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
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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
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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

Block II Lecture Exam 2 (2 decks)

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