Respiratory (Module 2) Flashcards
Sleep Apnea Pathophysiology
• can occur from several pathologic mechanisms, including CNS control over ventilation, poor circulation and oxygenation and airway obstruction
• breathing stops during sleep >10 s, >5x/hr
• muscles relax, tongue and other structures obstruct the airway (lower gas exchange aka hypoxemia, hypercapnia, reduced pH leading to sleeper waking up, sleep deprivation from repeating cycle)
Sleep Apnea Etiology/Genetic Risk
most common cause is upper airway obstruction by soft palate/tongue
contributing factors are: obesity, large uvula, short neck, smoking, enlarged tonsils or adenoids, oropharyngeal edema, male
genetic/congenital structure variations (achondroplasia)
Sleep Apnea Expected Findings
• snoring
• excessive daytime sleepiness
• inability to concentrate
• irritability
• bedwetting or excessive urination at night
• reduced sex drive, fatigue, depression
• pharyngeal edema
• increased risk of HTN, stroke, cognitive deficits, weight gain, DM, pulm and CV disease
• RESPIRATORY ACIDOSIS
Sleep Apnea Diagnostics
• STOP-Bang Sleep Apnea Questionnaire (score >3=high risk)
• pulmonary function tests (PFTs)
• sleep study (polysomnography)- directly observed for symptoms, depth of sleep, type of sleep (EEG), respiratory effort (ECG), O2 sat, muscle movement (EMG)
Sleep Apnea Meds
antidepressants
Modafinil (Provigil) not first line drug; may help with narcolepsy..doesn’t treat the cause wake up and smell the roses!
Sleep Apnea Procedures
ENT referral (adeniodectomy, uvulectomy, uvulopalatopharyngoplasty, trach in severe cases)
Sleep Apnea Nursing Care (Non-Surgical)
change of sleep position
weight loss
avoid alcohol
positive pressure ventilation
Continuous Positive Airway Pressure (CPAP/BiPAP) machine
avoid sedatives
CPAP (Continuous Positive Airway Pressure)
set and airway pressure continuously during each cycle of inhalation and exhalation
constant airflow
BiPAP (Bilevel Airway Pressure)
set inspire and airway pressure at beginning of each breath
low end exp pressure delivered at beginning of exhalation
more pressure when breathing in, less pressure when breathing out
APAP (Autotitrating Positive Airway Pressure)
adjusts continuously, resets pressure t/o the breathing cycle to meet needs
algorithmic control, automatically adjusts
Asthma Pathophysiology
intermittent and reversible airway obstruction; affects airway only not alveoli
occurs because of inflammation and bronchospasm
Asthma Triggers
allergens
cold air
airborne particles
ASA/NSAID-induced asthma (increased production of leukotrienes with inflammatory suppression, not true allergy)
exercise
food additives (MSG)
determine triggers, keep a diary
Asthma Expected Findings
audible wheezing
inc RR
DIB
inc cough
use of accessory muscles
barrel chest from air trapping (chronic), flattened diaphragm, inc intercostal spaces
long breathing cycle
cyanosis
hypoxemia
respiratory alkalosis
Asthma Risk Factors
genetic (AAT deficiency is a single gene disorder with many known gene variations and some increase risk for emphysema)
environmental
Asthma Labs
ABGS (low PaO2, low PaCO2 initially, high PaCO2 later)
Asthma Diagnostics
Pulmonary Function Tests (PFTs)…
forced vital capacity (FVC), forced expiratory volume (FEV1), peak expiratory flow rate (PEFR)
Forced Vital Capacity (FVC)
the total volume of air expired with max force
Forced Expiratory Volume in the 1st S (FEV1)
volume of air forcefully expired during the 1st second after taking a full breath
Peak Expiratory Flow Rate (PEFR)
green (80%- OK)
yellow (50-80%- caution, use rescue inhaler)
red (<50%- serious exacerbation, seek help and immediately use the reliever drugs)
Peak Flow Meter
recommended for pts who’s asthma is not well controlled
Asthma Meds
bronchodilators
short acting beta2 agonist (SABA)
albuterol
levalbuterol
long acting beta2, agonist (LABA)
salmeterol
cholinergic antagonist
ipratropium
tiotropium
anti-inflammatories
corticosteroids
fluticasone, beclomethasone
prednisone
leukotriene modifier
montelukast
Bronchodilators (Asthma)
cause bronchidilation through relaxing bronchiolar smooth muscle by binding to and activating pulmonary beta2 receptors
always administer before ICS to open airway and allow ICS to reach target better
exercise induced asthma: use bronchodilator inhaler 30 min before exercise
Short Acting Beta2 Agonist (SABA) (Asthma)
primary use is a fast acting reliever (rescue) drug to be used either during asthma attack or just before engaging in activity that usually triggers attack
Albuterol (ProAir, Proventil, Ventolin)(Asthma)
INHALED DRUG
teach pts to carry drug with them all all times because it can stop or reduce life threatening bronchoconstriction
SE: tachy
Levalbuterol (Xopenex) (Asthma)
teach pt to monitor HR because excessive use causes tachycardia
use them at least 5 min before other inhaled drugs
teach pt correct technique for using MDI or DPI
Long Acting Beta2 Agonist (LABA) (Asthma)
causes bronchodilation through relaxing bronchiolar smooth muscle by binding to and activating pulmonary beta2 receptors; onset of action is slow with long duration
primary use is prevention of an asthma attack
Salmeterol (Asthma)
INHALED DRUGS
teach pt to not use these drugs as reliever drugs because slow onset and don’t relieve acute symptoms
Cholinergic Antagonist (Asthma)
causes bronchodilation by inhibiting the parasympathetic nervous system, allowing the sympathetic system to dominate, releasing norepinephrine that activates beta2 receptors
purpose is to both relieve and prevent asthma and improve GAS EXCHANGE
Ipratropium (Atrovent, ApoIpravent) (Asthma)
INHALED DRUG FOR RELIEF AND PREVENTION
if pt is to use any of these as a reliever drug, teach them to carry it at all times because it can stop/reduce life threatening bronchoconstriction
Tiotropium (Spiriva) (Asthma)
INHALED DRUG
teach pt to increase daily fluid intake because it can cause mouth dryness
teach pt to observe for blurred vision, eye pain, headache, nausea, palpitations, tremors, inability to sleep
same for ipratropium
Anti Inflammatories (Asthma)
don’t cause bronchodilation
Corticosteroids (Asthma)
main purpose is to prevent an asthma attack caused by inflammation or allergies
Fluticasone and Beclomethasone (Asthma)
MDI INHALED DRUG
use drug daily even when no symptoms present, because max effectiveness requires continued use for 48-72 hrs
check mouth daily for lesions or drainage; good mouth care
Prednisone (Asthma)
PO
avoid anyone who has an upper respiratory infection because drug reduces all protective inflammatory responses which increases risk for infection
avoid activities that lead to injury because blood vessels become more fragile leading to bruising and petechiae
take drug with food to help reduce side effects of GI ulceration
don’t suddenly stop taking drug for any reason because drug suppresses adrenal production of corticosteroids
Leukotriene Modifier
purpose is to prevent asthma attack triggered by inflammation and allergies
Montelukast (Singulair)
PO (USE DAILY)
max effectiveness requires continued use 48-72 hrs
Stepwise Approach (Asthma)
Xanthine drugs (Theophylline, Aminophylline) might be used
not as common due to toxicity in adults and frequent blood draws for monitoring
Status Asthmaticus
severe and life threatening asthma attack that doesn’t respond to treatment (wheezing might diminish, NO AIR MOVEMENT!)
can develop into pneumothorax, cardiac/respiratory arrest and acidosis
TX:IV fluids, bronchodilators, steroids, epinephrine, O2 therapy, magnesium sulfate (rapid to relax muscles)
Asthma Nursing Care
improve airflow and gas exchange
self management education/personal asthma action plan (Peak Flow Meter for monitoring, trigger recognition/avoidance)
exercise/activity planning
O2 therapy
admin bronchodilator before steroid
INHALER: WAIT AT LEAST 1 MIN BETWEEN PUFFS
Allergies Pathophysiology
hypersensitivity is overactive immunity with excessive inflammation occurring in response to presence of antigen to which pt usually has been previously exposed
1st exposure: patient is “sensitized” and future exposures cause immune reaction; T’s tell Bs to create IgE specific to allergen, mast cells basophiks have IgE receptors with lots of IgE attached, allergen binds to IgE, causes degranulation
Allergies Causes
excessive production of IgE antibodies
allergens across body (inhalation, ingestion, injection)
contraction (latex, food, pollens, environmental proteins)
Allergies Expected Findings
sneezing
runny nose
red itchy watery eyes
genetic and environmental risk factors
Allergies Labs
ABGs
allergic asthma (inc serum eosinophil and IgE levels)
Allergies Diagnostics
take history and physical (upper airway, skin testing)
skin prick test (allergen prick, symptoms within 15 min)
intradermal skin testing (drug, venom or food allergies)
blood tests (IgE, RAST) (add allergen to blood sample to observe for reaction; high rate of false positives)
physician-supervised challenge test
patch test (contact dermatitis, checked after 48-96 hrs from application)
Allergies Meds
supportive therapy (no nasal washing)
vitamin C, zinc
steroids (anti inflammatories, reduces edema including airways, reduces mucous production)
leukotriene inhibitors (Montelukast)
antihistamines (Benadryl; diphenhydramine)
eye decongestants
decongestants (nasal (can cause rebound effect), PO); can produce rebound effect with extended use
bronchodilators
anti-inflammatories
antipyretics
mast cell stabilizers
Allergies Procedures
immunotherapy (desensitization/allergy shots) or therapy (SQ injection of low dose allergens increasing the amount slowly; full course=5 yrs)
decreased allergic response d/t competition; allergen in small amounts cannot bind to IgE, leading to IgG production against allergen, allergen attached to IgG instead of mast cell and IgG clears allergen from body
Allergies Complications
angioedema and anaphylaxis; can be fatal
potential for complete airway obstru from mucous swelling and anxiety from hypoxia
Chronic Bronchitis (COPD) Pathophysiology
chronic inflammation of bronchi and bronchioles
smoke/toxins trigger mucous glands and damage cilia -> reduced secretion clearance -> mucous plugs block airway -> leads to infections, hypoxemia, respiratory acidosis
Emphysema (COPD) Pathophysiology
decreased lung elasticity and hyperinflation of the lung
smoke/toxins raise proteases -> breaks down elastin in alveoli and small airway -> alveoli become damaged and enlarge into bullae -> air trapping, flattened/weak diaphragm -> increased work of breathing, accessory muscle use -> raised demand for O2 and disorganized breathing (inhalation starts before exhalation)
COPD Expected Findings
easily fatigued
frequent respiratory infections
use of accessory muscles to breathe
orthopneic (SOB that occurs lying down)
cor pulmonale (late)
thin
wheezing
pursed-lip breathing
chronic cough
barrel chest
dyspnea
prolonged expiratory time (respiratory acidosis)
digital clubbing of fingers (prolonged hypoxia)
COPD Risk Factors
genetic/environmental
SMOKING!!!
asthma -> 12x risk for COPD (Alpha1-antitrypsin (AAT) deficiency, recessive genetic; prevents proteases from breaking down protein
faulty gene + non smoker = no COPD
faulty gene + smoker = high risk COPD
2 faulty genes + non smoker = COPD at young age
COPD Labs
ABGs (could be grossly out of balance depending on severity of condition)
sputum samples
CBC (may show high WBC count, presence of infection)
H&H (high RBCs and iron levels; compensatory mechanisms for low O2 in blood)
BMP (serum electrolytes)
Serum AAT
COPD Diagnostics
PFTs
Chest X-ray (hyperinflation and FLATTENED diaphragm)
COPD Meds
similar to asthma
beta-andrenergics
cholinergic antagonists
mythylxanthines
corticosteroids
NSAIDs
mucolytics
COPD Procedures
lung transplant (rare)
lung reduction
COPD Complications
hypoxemia and acidosis
pneumonia and respiratory infections
right sided HF
pulmonary HTN
pneumothorax
skeletal muscle dysfunction
depression/anxiety
SMOKING CESSATION!
Diaphragmatic/Abdominal Breathing (COPD)
lie on back with knees bent or sit in chair
place hands or a book on abdomen to create resistance
begin breathing from abdomen while keeping chest still; you can tell if you’re breathing correctly if hands/book rises and falls accordingly
Pursed Lip Breathing
close mouth and breathe in through nose
purse your lips as you would to whistle; breath out slowly through mouth w/o puffing cheeks; spend at least twice the amount of time took you to breathe in
use abdominal muscles to squeeze out every bit of air you can
remember to use pursed lipped breathing during physical activity; always inhale before beginning and exhale while performing; never hold it in
Nicotine Patch
21 mg/patch; 4-6 weeks
nicotine at night may interfere with sleep, vivid dreams, but may help with morning cravings
remove ashtrays from view, healthy snacks, keep hands busy
Nicotine Gum
2 and 4 mg; 3-6 mths
absorbed through cheeks and gums; chew slowly until tingling is felt, place gum behind the cheek until tingling goes away for about 30 min
no coffee, soda or OJ for 15 min. before/during use
Lozenges
similar to gum but no chewing
Inhaler
prescription only
nicotine in the throat and mouth; irritation is common
Nasal Spray
prescription only
rapid but safe rise similar to smoking
Varenicline (Chantix)
decrease cravings; taken after eating with full glass of water; high risk with CV history
hallucinations, impaired judgement, nausea, abnormal dreams
Bupropion
antidepressant; 7-12 weeks; contraindicated in seizure/BPD, head trauma, anorexia, bulimia, excessive alcohol drinkers
dry mouth, difficulty sleeping
Nursing Care (Positioning)
unable to lay flat (orthopnea); sit upright 3 times a day for 1 hr
pace yourself to manage fatigue and activity intolerance, assess for issues with activity intolerance
pulmonary rehab and energy conservation
manage weight
Nursing Care (Effective Coughing)
often productive cough in the am; encourage cough and deep breathing
sit on chair/side of bed with feet on floor
turn shoulders in and head slightly down, hugging a pillow against chest (splinting)
take few breaths (3-4) trying to exhale fully
brace pillow, take a full breath and cough 2-3 times in same breath and repeat at least twice
Vibratory Positive Expiratory Pressure Devices
pt inhaled deeply and then exhaled through device, causing the ball to move and set up vibrations that are transmitted to chest and airways
O2 Therapy (COPD)
nasal cannula/40% venti mask (humidification!)
O2 sat of 88-92% is acceptable; otherwise, similar therapy to asthma
COPD Nursing Care
drug therapy (teach pt to self monitor the peak expiratory flow rates at home and adjust drugs as needed, manage anxiety with SOB)
suctioning as needed; encourage cough and clearing secretions
hydration/nutrition to support healthy weight (2L per day, high protein and calorie, pulmocare supplements may be needed; no dry/gas forming foods)
nutritionist consult
physical appearance (accessory muscle use), tripod positioning, enlarged neck muscle
no gas-forming foods
assess for activity intolerance; pace activity
O2 lvls 88-92%
COPD Goals of Therapy
maintain gas exchange (O2 sat 88%)
no cyanosis
cognitive integrity/orientation
coughing and clearing secretions effectively
RR and quality
TB Pathophysiology
airborne droplets inhaled
bacillus invades and multiplies in bronchi/alveoli
primary infection
acquired immunity (2-10, +ppd, immune response)
exudate
lesions in middle/lower lungs (caseous necrosis, calcification, primary lesions)
successful control= lesions resolve with little residual bacilli followed by latent TB
potential secondary TB infections or necrotic (liquified) lesions
active disease
TB Expected Findings
persistent cough, mucopurulent sputum, blood streaks (hemoptysis)
progressive fatigue, lethargy
nausea
anorexia
weight loss
irregular menses
low grade fever
night sweats
chills
TB Risk Factors
frequent close contact with infected person
immunocompromised
crowded conditions
older, homeless, disadvantaged
IVDU and ETOH users
lower SES
immigrants
TB Labs and Diagnostics
Nucleic Acid Amplification Test (NAAT) results in <2 hrs, tests secretions MOST ACCURATE AND RAPID
sputum culture typically 3x confirms diagnosis, can take 4 weeks
Bacille Calmette-Guerin (BCG) vaccine given in some countries; pts will show +PPD results, requires x-ray or blood analysis follow up
Tuberculin skin testing (TST)/Mantoux test (PPD) read in 48-72 hrs, raised area is measured; >10 mm=TB exposure or latent TB (>5 mm in immunocompromised) false negative in elderly or severely immunocompromised
blood analysis (+ means infected but doesn’t distinguish; QuantiFERON-TB Gold, T-SPOT TB, GeneXpert Omni)
+ PPD or blood analysis requires chest x-ray; can show active or healed lesions
TB Meds
combination drug therapy with strict adherence; TRIPLE ANTIBIOTIC THERAPY ORDERED FOR ACTIVE TB
isoniazid
rifampin
pyrazinamide
ethambutol
Isoniazid (INH, Hydrazide, PDP-Isoniazid) (TB)
kills actively growing bacteria outside cell and inhibits growth of dormant bacteria
take drug on empty stomach, avoid drinking and watch for signs of liver toxicity
Rifampin (RIF, Rifadin, Rimactane, Rofact)(TB)
kills slower-growing organisms, even those that reside inside macrophages and caseating granulomas
expect orange-reddish staining of skin and urine, and all other secretions to have a reddish-orange tinge and soft contact lenses will become permanently stained
reduces effects of oral contraceptives
Pyrazinamide (PZA) (TB)
can effectively kill organisms residing within the very acidic environment of macrophages, only combo with other TB drugs
ask pt for gout history, will make gout worse
be careful in sun and causes photosensitivity
Ethambutol (EMB, Etibi, Myambutol) (TB)
inhibits bacterial RNA synthesis; slow acting and bacteriostatic and used in combo with other TB drugs
can cause optic neuritis and can lead to blindness
TB Nursing Care
promote airway clearance (increase fluids, IS, TCDB)
prevent resistant TB (super TB)
airborne precautions (N95)
negative air pressure room (until 3 negative sputum cultures, around 3 mths treatment)
home (cover mouth and throw tissues in separate trash can, wear mask when in contact with crowds, can’t work until not infectious)
manage anxiety
improve nutrition
manage fatigue
care coordination/transition of care
DOH reporting and follow up
remind pt disease is not contagious after drugs have been taken for 2-3 consecutive weeks and clinical improvement is seen
DOT where healthcare professional watches pt swallow drugs magma be necessary in some situations. leads to more treatment successes, fewer relapses, less drug resistance
Seasonal Influenza
highly contagious acute viral respiratory infection
rapid onset of severe headache, muscle ache, fever, chills, fatigue, weakness, anorexia
preventable or reduced severity with vaccine
HANDWASHING
antiviral agents may be effective if started within 24-48 hrs of symptoms
COVID-19 History Assessment
upper respiratory symptoms
loss of taste/smell
vaccination status
exposure
overall activity and oxygenation
COVID-19 Physical Assessment
respiratory symptoms range in severity
fever/chills
cough
SOB
fatigue
muscle/body aches
headache
new loss of taste (ageusia) or smell (anosmia)
sore throat
n/v
diarrhea
abdominal pain
COVID-19 Unique/ER Symptoms
conjunctivitis
prothrombotic state (venous and arterial disease)
neurologic findings (encephalopathy with agitated delirium)
dermatologic findings, reddish nodules on distal digits (in YA)
trouble breathing
persistent pain/pressure in the chest
new confusion
inability to wake or stay awake
bluish lips or face
COVID-19 Diagnostics
heightened sense of fear
NAAT using RT-PCR
home antigen testing
antibody (serology) testing
chest imaging
pulse oximetry
COVID-19 Vaccine
recommended 6 mths or older
recommended 3 mths after recovery
Pulmonary HTN Pathophysiology
pulmonary vessels and often other lung tissues undergo growth changes that greatly increase pressure in lung circulatory system for unknown reasons
may lead to right ventricular failure and death
risk factors are collagen vascular disease, congenital heart problems, portal HTN, HIV, toxins, pregnancy
Pulmonary HTN Symptoms
dyspnea and fatigue
exertional intolerance
chest pain (late)
palpitations
dizziness
peripheral edema
as cites
adventitious lung and heart sounds
Pulmonary HTN Diagnostics
right sided cardiac catheterization (can measure pressures in lungs and heart)
echocardiogram to screen and rule out other causes
PFTs, V/Q scan
CT
blood samples for HIV or autoimmune disease rule out
sleep study (OSA)
Pulmonary HTN Surgery
respiratory/cardiac transplant
Pulmonary HTN Nursing Interventions
pulmonary rehab
mobility exercises
deep breathing/airway clearance
importance of med therapy adherence
respiratory infection prevention
How to Use Inhaler
- remove cap
- connect pieces
- shake
- exhale, place in mouth
- push
- breathe in slow
- remove, hold breath and breathe out
- wait 1 min between puffs
