NCM 102 lec respi

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NCM 102ALTERATION IN OXYGENATION

Lecture Series 02

GENERAL RESPIRATORY ANATOMY AND PHYSIOLOGY

I. General Respiratory Anatomy and PhysiologyA. The respiratory system is comprised of the upper airway and lower

airway structures.B. The upper respiratory system filters, moistens and warms air during

inspiration.C. The lower respiratory system enables the exchange of gases to

regulate serum PaO2, PaCO2 and Ph.

II. Upper RespiratoryA. Nose and sinuses

1. Filters, warms and humidifies air2. First defense against foreign particles3. Inhalation for deep breathing is to be done via nose4. Exhalation is done through the mouth

B. Pharynx1. Behind oral and nasal cavities2. Nasopharynx

a. behind nose

NCM 102 Med-Surg Nsg Respiratory Disorders

Prepared by: Lindsay Carmelle I. Nate, R.N.



b. soft palate, adenoids and eustachian tube3. Oropharynx

a. from soft palate to base of tongueb. palatine tonsils

4. Laryngopharynxa. base of tongue to esophagus

b. where food and fluids are separated from airc. bifurcation of larynx and esophagus

C. Larynx1. Between trachea and pharynx2. Commonly called the voice box3. Thyroid cartilage - Adam's apple4. Cricoid cartilage

a. contains vocal cordsb. the only complete ring in the airway

5. Glottis - opening between vocal cords6. Epiglottis - covers airway during swallowing

III. Lower Respiratory and Other Structures

A. Trachea1. Anterior neck in front of esophagus2. Carries air to lungs

B. Mainstem bronchi1. Right and left2. Right is more vertical, so right middle lobe is more likely to

receive aspirate into it with the result of aspiraton pneumonia,which is more commonly found in elderly populations





C. Conducting airways1. Lobar bronchi

a. surrounded by blood vessels, lymphatics, nervesb. lined with ciliated, columnar epithelial cellc. cilia move mucus or foreign substances up to larger

airways

2. Bronchiolesa. no cartilage; collapse more easilyb. no ciliac. do not participate in gas exchange

D. Alveolar ducts and alveoli1. Lungs contain approximately 300 million alveoli2. Alveoli surrounded by capillary network3. Gas exchange area (blood takes O2, gives off CO2)4. Gas exchange happens at alveolar-capillary membrane (al-cap

memb)5. Held open by surfactant which decreases surface tension to

minimize alveolar collapse

E. Accessory muscles of respiration1. Scalene muscles - elevate first two ribs2. Sternocleidomastoid - raise sternum3. Trapezius and pectoralis - stabilize shoulders4. Abdominal muscles - puts power into cough and used most often

with chronic respiratory problems and acute severe respiratorydistress

IV. PhysiologyA. Basic gas-exchange unit of the respiratory system is the alveoli.B. Alveolar stretch receptors respond to inspiration by sending signals to

inhibit inspiratory neurons in the brain stem to prevent lung overdistention.

C. During expiration stretch receptors stop sending signals to inspiratoryneurons and inspiration is ready to start again.

D. Oxygen and carbon dioxide are exchanged across the alveolar capillarymembrane by process of diffusion.

E. Neural control of respirations is located in the medulla. The respiratorycenter in the medulla is stimulated by the concentration of carbondioxide in the blood.

F. Chemoreceptors, a secondary feedback system, located in the carotidarteries and aortic arch respond to hypoxemia. These chemoreceptorsalso stimulate the medulla.

G. Ph regulation1. Blood Ph (partial pressure of hydrogen in blood): a decrease in

blood Ph stimulates respiration hyperventilation, both throughthe neurons of the brain's respiratory center and through thechemoreceptors in carotid arteries and aortic arch.

2. Blood PaCO2 (partial pressure of carbon dioxide in arterialblood): an increase in the PaCO2 results in decreased blood Ph,and stimulates respiration.





3. Blood PaO2 (partial pressure of oxygen in arterial blood): adecrease in the PaO2 results in a decreased blood Ph,stimulating respiration.

4. When arterial Ph rises or the arterial PaCO2 falls, hypoventilationoccurs.

FUNCTION

A. Primary functions of the respiratory system1. Provides oxygen for metabolism in the tissues2. Removes carbon dioxide, the waste product of metabolismB. Secondary functions of the respiratory system1. Facilitates sense of smell2. Produces speech3. Maintains acid-base balance4. Maintains body water levels5. Maintains heat balance

ASSESSMENT OF RESPIRATORY FUNCTION

A. DIAGNOSTIC STUDIES

Chest x-ray film (radiograph)> Provides information regarding the anatomical location andappearance of the lungsNursing ResponsibilitiesPreprocedurea. Remove all jewelry and other metal objects from the chest area.

b. Assess the client's ability to inhale and hold his or her breath.c. Question women regarding pregnancy or the possibility of pregnancy.

Sputum specimen> Specimen obtained by expectoration or tracheal suctioning toassist in the identification of organisms or abnormal cellsPreprocedurea. Determine specific purpose of collectionb. Obtain an early morning sterile specimenc. Instruct the client to rinse the mouth with water before collection.d. Obtain 15 mL of sputum.e. Instruct the client to take several deep breaths and then deeply to

obtain sputum.f. Always collect the specimen before the client begins antibiotictherapy.3. Postprocedurea. If a culture of sputum is prescribed, transport the specimen to thelaboratory immediately.b. Assist the client with mouth care.

Bronchoscopy





> Direct visual examination of the larynx, trachea, and bronchi with afiberoptic bronchoscope

Preprocedurea. Obtain informed consent.b. NPO post midnight

c. Obtain vital signs.d. Remove dentures or eyeglasses.e. Prepare suction equipment.Postprocedurea. Monitor vital signs.b. Maintain the client in a semi-Fowler's position.c. Assess for the return of the gag reflex.d. Maintain NPO status until the gag reflex returns.e. Have an emesis basin readily available for the client to expectoratesputum.f. Monitor for bloody sputum.g. Monitor respiratory status

h. Monitor for complicationsi. Notify the physician if fever, difficulty in breathing, or other signs of complications occur following the procedure.

Pulmonary angiography> An invasive fluoroscopic procedure in which a catheter is insertedthrough the antecubital or femoral vein into the pulmonary artery orone of its branches> Involves an injection of iodine or radiopaque contrast materialPreprocedurea. Obtain informed consent.b. Assess for allergies to iodine, seafood, or other radiopaque dyes.c. NPO for 8 hours before the procedure.d. Monitor vital signs.e. Assess results of coagulation studies.f. Establish an intravenous access.g. Administer sedation as prescribed.h. Instruct the client to lie still during the procedure.i. Instruct the client that he or she may feel an urge to cough, flushing,nausea, or a salty taste following injection of the dye.

j. Have emergency resuscitation equipment available.Postprocedurea. Monitor vital signs.b. Avoid taking blood pressures for 24 hours in the extremity used forthe injection.c. Monitor peripheral neurovascular status of the affected extremity.d. Assess insertion site for bleeding.e. Monitor for delayed reaction to the dye.

Thoracentesis> Removal of fluid or air from the pleural space via a transthoracicaspirationPreprocedurea. Obtain informed consent.





b. Obtain vital signs.c. Assess results of coagulation studies.d. Place client in sitting position, with the arms and shoulderssupported by a table at the bedside during the procedure.e. If the client cannot sit up, the client is placed lying in bed toward theunaffected side, with the head of the bed elevated.

f. Instruct the client not to cough, breath deeply, or move during theprocedure.Postprocedurea. Monitor vital signs.b. Monitor respiratory status.c. Apply a pressure dressing, and assess the puncture site for bleedingand crepitus.d. Monitor for signs of pneumothorax, air embolism, and pulmonaryedema.

Lung biopsy> A percutaneous lung biopsy is performed to obtain tissue for analysisby culture or cytological examination.Preprocedurea. Obtain informed consent.b. Maintain NPO status of the client before the procedure.c. Inform the client that a local anesthetic will bed. Administer analgesics and sedatives as prescribed.Postprocedurea. Monitor vital signs.b. Apply a dressing to the biopsy site and monitor for drainage orbleeding.c. Monitor for signs of respiratory distress.d. Monitor for signs of pneumothorax and air emboli, and notify thephysician if they occur.

Pulse Oximetry

measures oxygen saturation of hemoglobin

90-100%

Arterial Blood Gas Analysis

measures concentrations of blood gases and identifies acid basebalance of the body

use of arterial blood

Pulmonary Function Test

Measures lung volumes and capacity

Done by respiratory therapists; painless; client will breath into amachine

Tidal volume (VT)- volume of inhaled and exhaled during normal andquiet breathing

Inspiratory reserve volume (IRV)- maximum amount of air that can beinhaled over and above the normal breath

Expiratory reserve volume maximum amount of air that can beexhaled following a normal exhalation

Residual volume (RV)- amount of air remaining in the lungs aftermaximal exhalation





Total lung capacity (TLC)- total volume of lungs at maximum inflation;VT + IRV + ERV + RV

Vital capacity (VC)- total amount of air that can be exhaled after amaximal inspiration; VT+ IRV + ERV

Inspiratory capacity- total amount of air that can be inhaled followingnormal quiet respiration; VT + IRV

Functional residual capacity (FRC)- volume left in the lungs afternormal exhalation; ERV +RV

Minute volume (MV)- total amount of air breathed in one minute

B. COMMON SIGNS AND SYMPTOMS:

Cough

Most common sign of respiratory disease

Caused by irritation of mucous membranes

Chief protection against accumulation of secretions and foreignbody

Chest pain: may indicate hypoxia or damage to lungs Cyanosis and Clubbing of fingers: indicates hypoxia

Hemoptysis: blood expectorated from the respiratory tract; caused bytrauma or break in the continuity of respiratory tract

Effort in breathing: Dyspnea or Orthopnea

Sputum production

Reaction of lungs to constantly recurring irritation

Thoracic sounds

Crackles: loud, low pitched bubbling sound; results from air passingthrough fluid

Wheezes: musical sound; caused by air passing through narrowed

airways Stridor: loud, high pitched crowing sound

Friction rub: grating, loud harsh sound

Ronchi: sounds likes snores or moans

Chest Configuration- AP: L= 1:2

Barrel chest- increase in AP diameter

Pigeon chest- increase in AP diameter; results from sternaldisplacement

Funnel chest- depression of lower portion of sternum

C. HISTORY:

1. Current respiratory problems:

Changes in breathing pattern

Activities that may cause symptoms

How many pillows used at night2. History of respiratory disease

Any respiratory diseases or infections

Frequency of occurrence





Exposure to pollutants3. Lifestyle

Smoking history

Exposure to smoke and other respiratory irritants

Alcohol use

Exercise pattern4. Presence of cough

How often

When does it occur

Productive or dry5. Description of sputum

When it is produced

Amount, color, thickness, odor

Presence of blood

6. Presence of chest pain

Location

Description

Does it occur with inspiration or expiration

How long does it affect breathing

Aggravating and alleviating factors7. Presence of risk factors

History of respiratory diseases in the family8. Medication History

OTC prescriptions for breathing e.g. bronchodilators

UPPER RESPIRATORY DISEASES

RHINITIS

Allergic Rhinitis

Definition: is a group of disorders characterized by inflammation and irritation of the mucous membranes of the nose.It may be classified as nonallergic or allergic.Rhinitis may be an acute or chronic condition.

Cause: pollen, flowers, grasses and occur in spring/fall; last several weeks

while allergens are high.

.





Signs/Symptoms: rhinorrhea (excessive nasal drainage, runny nose)nasal congestion

nasal discharge (purulent with bacterial rhinitis)nasal itchinesssneezingHeadache may occur, particularly if sinusitis is also present.

Treatment: Identify and avoid triggersAntihistaminesDecongestantsDesensitization

Acute Viral Rhinitis

Definition: Common cold (“acute coryza”).used when referring to an upper respiratory tract infection that is self-

limited and caused by a virus (viral rhinitis).

Cause: Virus that invades the upper respiratory tract. Is the most prevalentinfectious disease in the world and is spread by airborne droplets.

Signs/Symptoms: malaisefever/chillsheadachenasal discomfortdry, sore throatcough (either productive or nonproductive)mild leukocytosis

*Complications: laryngitis, sinusitis, otitis media, tonsillitis, and lung infection.

Treatment: no specific treatment for the common cold or influenza.Symptomatic therapy.Some measures include

providing adequate fluid intake

encouraging rest

increasing intake of vitamin C

using expectorants as needed.

Warm salt-water gargles soothe the sore throat





nonsteroidal anti-inflammatory agents (NSAIDs) such as aspirin oribuprofen relieve the aches, pains, and fever in adults.

Antihistamines are used to relieve sneezing, rhinorrhea,

Nasal congestion. Topical (nasal) decongestant agents

Echinacea, an herbal therapy, stimulates immune system and hasantibacterial and anti-inflammatory properties. Considered safe

when taken at recommended doses for 10 to 14 days. Do not takefor more than 8 weeks. Patients with immune disorders should notuse Echinacea.

INFLUENZA

Definition: “Flu”

Cause: Three groups of viruses (A, B & C, though C has little pathogenic

effects)

Signs/Symptoms: Abrupt onset of cough, fever, and myalgia often accompanied byheadache and sore throat. Symptoms of uncomplicated flu usuallysubside within 7 days. Some experience weakness and lassitude,hyperactive airways and chronic cough that may persist for weeks

(older adults, especially).PNEUMONIA is the most common complication of flu.

Diagnostic Tests: Viral cultures or throat or nasal swabbingsCulture and Sensitivity Test

Treatment: Vaccine is 70 to 90% effective in preventing flu when given in the fall(mid-Oct) before exposure occurs. Treatment is primarily symptomaticAcetaminophen is given for fever, headache, and myalgiaRest and increase fluid intakeAntiviral Zanamivir(Relenza) and Oseltamivir (Tamiflu)Amantadine (Symmetrel)

Other viral infection

Bird Flu

SARS

aH1N1

LOWER RESPIRATORY DISEASES

ACUTE BRONCHITIS

Definition: Inflammation of the bronchi in the lower respiratory tract usually due

to infection.

Cause: Usually occurs as a complication of an upper respiratory tract infection

brought on by a virus (rhinovirus, influenza, corona virus, respiratory

synctial virus (RSV), adenovirus, influenza A and B, parainfluenza).

Bacterial infections are also common

Signs/Symptoms: ChillinessMalaise





Soreness and constriction behind the sternum-worse patient coughSlight feverCough, at first dry and painful; later, green or yellowish sputum with

pus cellsPersistent cough following an acute upper airway infection

(rhinitis/pharyngitis)

Diagnosis: When symptoms are severe, chest x-rays can differentiate acutebronchitis from pneumonia (acute bronchitis has no evidence of

consolidation or infiltrates).

Treatment: Usually self-limiting; treatment is supportive…

• Fluids

• Rest

• Anti-inflammatory agents

• Antiviral medications

• Cough suppressant or bronchodilators for symptomatictreatment of nocturnal cough/wheezing

• Other symptom relief to reduce complaints

PNEUMONIA

Definition: An acute inflammation of the lung parenchyma that commonly impairs

gas exchange.

Cause: Pneumonia may be viral, bacterial, fungal, protozoal (parasitic), or

chemical in origin.

Bacterial pneumonia:

• Infection initially triggers alveolar inflammation and edema,which produces an area of low ventilation with normalperfusion.

• Capillaries become engorged with blood, causing stasis.

• As alveolocapillary membrane breaks down, alveoli fill withblood and exudate, resulting in atelectasis (lung collapse)

• Lungs look heavy and liver-like.

Viral pneumonia:

• The virus first attacks bronchiolar epithelial cells, which causesinterstitial inflammation and desquamation.

• The virus also invades bronchial mucous glands and gobletcells.

• It spreads to the alveoli, which fill with blood and fluid.

Aspiration pneumonia:

• Inhalation of gastric juices or hydrocarbons triggerinflammation and inactivates surfactant over a large area.





• Decreased surfactant leads to alveolar collapse.

• Acidic gastric juices may damage the airways and alveoli.Particles containing aspirated gastric juices may obstruct theairways and reduce airflow, leading to secondary bacterialpneumonia.

Types & Classifications:Community-Acquired Pneumonia (CAP)

• “A lower respiratory tract infection of the lung parenchymawith onset in the community or during the first 2 days of hospitalization.”

• Highest incidence in winter months

• Smoking is a high risk factor

Hospital-Acquired Pneumonia (HAP)

• “Pneumonia occurring 48 hours or longer after hospitaladmission and not incubating at the time of hospitalization.”

• Risk for HAP in mechanically ventilated patients is 6 to 20times higher than other patients.

• Inpatient mortality rates much higher than mortality for CAP(1-5% vs. 12%)

Aspiration Pneumonia

• “The sequelae occurring from abnormal entry of secretions orsubstances into the lower airway. Usually follows aspiration of material from the mouth or stomach into the trachea andsubsequently the lungs.”

• Usually patient has a history of loss of consciousness (seizure,anesthesia, head injury, stroke, alcohol intake), with gag andcough reflex depression or is on tube feedings.

Opportunistic Pneumonia

• Affects patients with compromised immune systems.

o Pneumocystis carinii = HIV/AIDS. Chest x-ray shows

diffuse bilateral alveolar pattern of infiltration. Inwidespread disease, lungs are massively consolidated. Treat with Bactrim.

o Cytomegalovirus (type of herpes virus) = organ

transplant patients. Gives rise to latent infections andreactivation with virus shedding. May be mild or canbe fulminant and produce pulmonary insufficiencyleading to death. In pneumonia, may be combinedwith other bacteria and fungi. Treat with Cytovene.

Signs/Symptoms:







o Chronic illness (lung/heart disease; diabetes)

o Recovering from severe illness

o 65 years or older

o Living in a long-term care facility

Nutritional therapy

• Fluid intake of at least 3 L per day to support treatment; mayneed to be administered by IV

• Minimum of 1500 calories per day

• Eat small, frequent meals.

Role of Nurse: Goals

• Clear breath sounds

• Normal breathing patterns

• No signs of hypoxia

• Normal chest x-ray

• No complications related to pneumonia

TUBERCULOSIS

Definition: An infectious disease caused by Mycobacterium tuberculosis. Usually

involves the lungs, but may occur in the larynx, kidneys, bones,

adrenal glands, lymph nodes and meninges and can be disseminated

throughout the body.

Cause: M. tuberculosis is a gram-positive, acid-fast bacillus that is spread from

person to person via airborne droplets, which are produced when the

infected individual with pulmonary or laryngeal TB coughs, sneezes,

speaks or sings.

Risk factors:

• Poor, under-served minorities

• Homeless people

• Residents of inner-city neighborhoods

• Foreign-born people

• Older adults

• Institutionalized people

• IV/injection drug users

• Socioeconomically disadvantaged

• Medically underserved of all races

•

Immunosuppressed people (HIV, cancer, organ transplant)• Health care workers

TB is not highly infectious and transmission usually requires close,

frequent or prolonged exposure.

Signs/Symptoms:





Diagnosis:

Tuberculin Skin Testing

o Antigen/Antibody reaction test…uses purified proteinderivative (PPD) of tuberculin to detect TB antibodies from aprevious immune response.

o Once acquired, sensitivity to TB persists throughout life.

o Reaction of >5 mm induration is positive for patients with…

o Recent close contact with person diagnosed withinfectious TB

o Chest x-ray with fibrotic lesions likely to be healed TB

o Known or suspected HIV infection

o Organ transplants and other immunosuppressive

conditions

o Reaction of >10 mm induration is positive for patients…

o With other medical risk factors known to substantiallyincrease risk of TB once infection has occurred(diabetes, renal disease, cancer)

o Who recently immigrated from (in past 5 years) fromareas of high prevalence

o Who are medically under-served or homeless

o Who reside in long-term care facilities and prisons

o Who use IV drugs







o Patient will take appropriate measures to prevent the spread of disease.

Interventions:

o Assess symptomatic patient for exposure to persons with TB.

o Patients strongly suspected of having TB should…

o Be placed on respiratory isolationo Receive four-drug therapy

o Receive an immediate medical work-up, includingchest x-ray, sputum smear and culture

o Use a negative pressure isolation room that offers six

or more exchanges per hour to isolate patient.

o Teach patient to cover the nose and mouth with paper tissueevery time he or she coughs, sneezes or produces sputum. The tissues should be burned, flushed down the toilet orthrown into a paper bag and disposed of with the trash.

o Instruct the patient about certain factors that could reactivate

TB such as immunosuppressive therapy, malignancy andprolonged debilitation.

OBSTRUCTIVE PULMONARY DISEASE

The most common chronic lung diseases and are characterized by increased resistance to

airflow as a result of airway obstruction or airway narrowing.

Includes four conditions:

o Asthma (allergic reaction)

o Emphysema (COPD)

o Chronic Bronchitis (COPD)

ASTHMA

Definition: An obstructive pulmonary disease characterized by airway inflammation, and

non-specific hyperirritability or hyper-responsiveness of the tracheobronchial

tree (bronchospasm). The hyper-responsiveness seen in asthma is caused

by bronchoconstriction in response to physical, chemical and

pharmacological agents.

Cause: Allergens

• Exaggerated allergic response (IgE) to environmental factors (dust,pollen, grass, mites, roaches, mold, dander, etc.).

Exercise

• “Exercise-Induced Asthma”

• Occurs within several minutes of vigorous exercise

Respiratory Infections

• Most common precipitating factor of an acute asthma attack.





• Bacterial infections cause inflammatory changes

Nose, Sinuses and Drugs/Food Additives

• “Asthma-Triad”….Nasal polyps, asthma, sensitivity to aspirin andNSAIDS

• Nose and Sinus Problems

o Allergic rhinitis (seasonal or perennial) and nasal polyps

contribute to asthma problems

o Treat/prevent sinusitis and remove large nasal polyps

• Drug Allergies

o Exposure to ASA/NSAIDS = wheezing within 2 hours

o Avoid Beta blockers (propranolol, timolol, other “-olol” drugs)

o Avoid ACE inhibitors

• Food Allergies

o Avoid exposure to Tartrazine (yellow dye #5 found in manyfoods)

o Avoid vitamins

o Avoid sodium metabisulfite (food preservative in fruit,beer/wine and salad bars).

Emotional Stress

• Psychological or emotional stress may be a trigger

• Panic and anxiety during an attack may exacerbate and prolong theattack

Signs/Symptoms:





Early-Phase Response

bronchospasm

inflammatory response.

Immediate response that peaks within 30 to 60 minutes of exposure tothe trigger.

Symptoms: wheezing, chest tightness, dyspnea and cough.

Late-Phase Response

Characterized by inflammation, constriction of bronchioles andexcess mucus.

Late-phase response peaks 5 to 6 hours after exposure and may lastfor days.

WBC infiltration

This activity increases airway reactivity which worsens the symptomsof future attacks, and makes them easier to trigger.

increased work of breathing.

airway remodeling.

Clinical Manifestations of asthma:

• Recurrent episodes of wheezing, breathlessness, dyspnea, chesttightness and cough (particularly at night and in the early morning)after exposure to a trigger

• Characterized by prolonged expiration (wheezing upon expiration, airtrapping and hyperinflation).

• Diminished or absent breath sounds during attack is an ominous sign

• Person may sit upright or slightly bent forward using the accessory

muscles of respiration to try to get enough air.

• Attacks may last a few minutes to several hours.

• Symptoms of hypoxia occur: restlessness, anxiety, inappropriatebehavior, increased pulse and blood pressure, significantly increasedrespiratory rate (>30 breaths per minute) with use of accessorymuscles.

* Status Asthmaticus

• Severe, life-threatening attack that does not respond to usualtreatment.

• “The longer it lasts, the worse it gets and the worse it gets, thelonger it lasts.”

• Caused by viruses; aspirin/NSAIDS; stress; environmental pollutants;allergens; abrupt discontinuation of drug therapy (corticosteroids);abuse of aerosol medication; use of beta-blockers.

• Symptoms same as asthma, but more severe and more prolongedwith extreme anxiety, fear of suffocation, diaphoresis and severelyincreased work of breathing.

• Chest remains in hyperinflated state; hypertension, sinus tachycardiaand ventricular arrhythmias may occur (related to hypoxemia).





Diagnosis:

• History and physical examination

• Pulmonary function studies including response to bronchodilatortherapy

• Peak expiratory flow monitoring

• Chest X-Ray

• Measurement of ABGs or Oximetry

• Allergy skin testing (if indicated)

• Blood level of eosinophils and IgE.

Treatment: Acute Episode:

o Oxygen therapy immediately with pulse oximetry and ABGs

o Inhaled B2-agonists by metered-dose inhaler (MDI) with

spacer or nebulizer every 20 minutes to 4 hours asnecessary.

o If no response in 30 to 60 minutes, use oral corticosteroids,or if severe—IV corticosteroids. IV aminophylline may beconsidered, but effectiveness is questionable.

o Continue treatment until patient breathes comfortably,

wheezing has stopped and pulmonary function results arenear baselines.

• Status Asthmaticus:

o Correct hypoxemia and improve ventilation

o Same interventions as for acute asthma (above), but may

need to increase the frequency and dose of inhaledbronchodilators to 2 to 6 puffs every 5 to 20 minutes(depending upon medication).

o Continuous monitoring of patient is critical.

o If B2-agonists do not work, use IV corticosteroids

(methylprednisolone) every 4 to 6 hours (peaks in 12 hours).

o IV mag sulfate and subcutaneous epinephrine may act asbronchodilators. If administered, monitor BP and EKGclosely.

o Oxygen therapy and IV fluids (for hydration) are usually

required.

o Severe, non-responsive attacks may require mechanicalventilation.

•Even after bronchospasm resolves, inflammation, edema, andviscous mucus plugs remain for several days.

• Drug classifications

o Two categories:

Long-term control (achieve/maintain control of persistent asthma)

• Coricosteroids (anti-inflammatory)





Quick-relief (treat symptoms and exacerbations)

• Mast cell stailizers (cromolyn, nedocromil)

• Bronchodilators

o B2-agonists (albuterol)

o

Anticholinergics (Atrovent)o methylxanthine derivatives

(theophylline)

Role of Nurse: Interventions

• Administer oxygen

• Administer bronchodilators

• Perform chest physiotherapy

•

Administer medications as ordered• Continuously monitor patient’s condition

• Monitor effectiveness of treatments

• Decrease the patient’s sense of panic; encourage slow breathingusing pursed lips for prolonged exhalation

• Provide rest and a quiet, calm environment for the patient

COPD/EMPHYSEMA & CHRONIC BRONCHITIS

Definition: Group of diseases with the major characteristic of airflow obstruction and

hyper-reactivity of airway. Symptoms include difficulty with exhalation

caused by airway obstruction from edema or excessive mucus production.

Lung hyperinflation causes alveolar air trapping and leads to frequent

pulmonary infections. Symptoms are usually progressive and irreversible.

Emphysema: an abnormal, permanent enlargement of the airspaces distal

to the terminal bronchioles, accompanied by destruction of their walls and

without obvious fibrosis.

Chronic Bronchitis: the presence of a chronic productive cough for 3

months in each of 2 successive years in a patient in whom other causes of

chronic cough have been excluded.





Cause: Cigarette Smoking….

Infection

Heredity

Aging

Signs/Symptoms: Emphysema:

• Two types…but may overlap in some patients

o Centrilobular









• Improve quality of life as much as possible

• Avoid environmental pollutants

• Treat infections immediately

• Stop smoking

Drug therapy:

• Bronchodilators (as a maintenance therapy, not for acute symptoms)

o Beta-2 agonists are commonly used

o MDI or nebulizer

o Anticholinergics are more effective in emphysema

• Oxygen therapy

o Raises the partial pressure of O2 in inspired air to treat

hypoxemia

o Humidification and nebulizers

O2 is dry and irritating and must be humidified beforedelivery

o Complications of O2 Therapy

Combustion

CO2 Narcosis (“Oxygen-Drive” for breathing may geteliminated if oxygen is administered)

O2 Toxicity (from prolonged exposure to O2; mayinactivate pulmonary surfactant and lead to ARDS(acute respiratory distress syndrome).

Infection (humidity encourages growth of bacteria inlungs)

Respiratory Therapy

• Breathing retraining (pursed lip breathing; diaphragmatic/abdominal;practice 8 -10 reps; 3-4 x per day )

• Effective coughing techniques

• Chest physiotherapy

• Exercise; pulmonary conditioning; smoking cessation and COPDsupport groups

Nutritional Therapy

• Maintain weight

• Rest for 30 minutes before eating

• Use bronchodilator before meals

• Eat five to six small meals (avoid bloating which puts pressure ondiaphragm)

• Liquid/pureed diets may be helpful

• Avoid foods that require a lot of chewing





• Avoid exercise within 1 hour of eating

• Bloating/early satiety may be related to swallowing air, position of diaphragm or side effects of meds

• High calorie/high protein recommended for emphysema

• High carbs metabolize into high CO2, and should be avoided

• Fluid intake should be at least 3 L per day unless contraindicated,and between meals rather than with meals

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NCM 102 lec respi