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RESPIRATORY DISORDERS
ACUTE BRONCHITIS
- infection of the lower respiratory tract the major bronchi that is generally an acute consequence of URTI.
PATHOPHYSIOLOGY/ETIOLOGY
primarily viral but may also arise from bacterial agents, by exposure to irritants areas of the bronchial wall inflamed and irritated and mucus increases. As a result, the air passageway is narrowed Virus can damage the epithelial cells that lines the bronchi and narrowing of airways with impairment or limitation of amount of air flowing into the lungs. If the impairment of airflow is severe, person may manifest shortness of breath. The impairment of airflow is triggered by inhaling mild irritants, outdoor air and smelling strong odors.
Two types A. Infectious bronchitis Occurs most during winter and often caused by VIRUS- influenza virus It may be caused by bacteria- mycoplasma Pneumoniae, Chlamydia Pneumoniae- Young adults Bacterial bronchitis –middle adulthood- Streptococcus pneumonia and Moraxella catarrhalis
B. Irritative bronchitis Also called industrial or environmental bronchitis Caused by exposure to various mineral and vegetable dust
Exposure to fumes from strong acids, amonia
Clinical Manifestations Productive cough and Wheezing - in two 2-3 days and worst at night (clear to purulent sputum) Dyspnea, Fever Tachypea occasional Pleuritic chest pain Diffuse rhonchi and crackles heard on auscultation heard on auscultation
Diagnostic Evaluation
Chest X-ray No evidence of infiltrates or consolidation Based on signs-Productive cough-(clear to white sputum- VIRAL , Yellow or Green- BACTERIA )
Nursing Diagnosis Ineffective airway clearance related to sputum productions and inflammation of lower airways
Nursing interventions Encourage mobilization of secretions through hydration, and cough. -Increase fluid intake -Avoid beverages like caffeine or alcohol- it does not promote hydration because of their diuretic effect. Employ Chest physiotherapy Antibiotics for 7-10 days- indicated with underlying respiratory problem (amoxicillin,
doxycycline, cefaclor, cefuroxime, levofloxacin Bronchodilators - for bronchospastic cough and bronchial irritation-dilate the bronchi and open the airways to reduce wheezing. Cortecosteroids - to reduce cough, inflammation and hyperactivity to airways. Expectorants- to excrete phlegm Acetamenophen, ibuprophen - to reduce fever Avoid the use of cough suppressants, antihistamines, and decongestant- it causes drying and retention of secretions.
Health Teachings Instruct patient on the treatment regimen regarding the completion of the course of antibiotics Encourage patient to seek medical attention for shortness of breath and worsening condition Inform the patient that a dry cough may persist after bronchitis due to irritation of the airways If patient is not treated with antibiotics, assure patient that majority recover from bronchitis without antibiotic treatment. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
- pulmonary disease that causes chronic obstruction of airflow from the lungs
- A progressive and irreversible condition characterized by diminished inspiratory and expiratory capacity of the lungs.
Keys Point for COPD:
Limited Airflow (due to thick and swollen bronchioles that have become deformed with excessive sputum production and this narrows the airways) Inability to fully exhale (due to loss of elasticity of the alveoli sacs from damage and the sacs start to develop air pockets) Irreversible once developed … cases vary among people from mild to severe…managed with lifestyle changes and medications. Happens gradually ….most people start to notice signs and symptoms middle-aged and will present with dyspnea with activity they could normally tolerate, recurrent lung infections, chronic cough etc. COPD is a term used as a “catch all” for diseases that limit airflow and cause dyspnea
Types of COPD
Emphysema “pink puffers” Chronic bronchitis “blue bloaters” ETIOLOGY OF COPD Cigarette smoking, Air pollution, occupational exposure aggravate the disease Allergy, autoimmunity Infection Aging, genetic predisposition Alpha1 anti trypsin deficiency Genetically the cause of EMPHYSEMA
- serves as primary inhibitor of neutrophil elastase - an elastin degrading protease released by neutrophils. When alveolar structures are left unprotected from exposure to elastase, progressive destruction of elastin tissue s results to emphysema.
Normal breathing:
In the later stage, CO INCREASES and the O decreases further.
PULMONARY EMPHYSEMA (PINK
PUFFERS)
it is characterized by destruction of alveoli; enlargement of distal airspaces (over distension of non-functional alveoli) Destruction of the alveoli, narrowing of small airways and trapping of air resulting in loss of lung elasticity and breakdown of alveolar walls The name comes from hyperventilation (puffing to breathe) and pink complexion (they maintain a relatively normal oxygen level due to rapid breathing) rather than cyanosis as in chronic bronchitis. In emphysema, the alveoli sacs lose their ability to inflate and deflate due to an inflammatory response in the body. So, the sac is unable to properly deflate and inflate. Inhaled air starts to get trapped in the sacs and this causes major hyperinflation of the lungs because the patient is retaining so much volume. Hyperinflation causes the diaphragm to flatten. The diaphragm plays a huge role in helping the patient breathe effortlessly in and out. Therefore, in order to fully exhale, the patient starts to hyperventilate and use accessory muscles to get the air out now. This leads to the barrel chest look and during inspect it may be noted there is an INCREASED ANTEROPOSTERIOR DIAMETER. The damage in the sacs cause the body to keep high carbon
dioxide levels and low blood oxygen levels. Inhaled oxygen will not be able to enter into the sacs for gas exchange and carbon dioxide won’t leave the cells to be exhaled. The body tries to compensate by causing hyperventilation (increasing the respiratory rate… hence puffer) and the patient will have less hypoxemia “pink complexion” than chronic bronchitis who have the cyanosis because pink puffers keep their oxygen level just where it needs to be from hyperventilation.
Remember: Lung Damage
L ack of energy U nable to tolerate activity (shortness of breath) N utrition poor (weight loss) due to energy used breathing especially with emphysema G ases abnormal (high PCO2 >45 and low PO2 <90)..respiratory acidosis D ry or productive cough constant (productive with chronic bronchitis) A ccessory muscle usage during breathing, A bnormal lung sounds: diminished, coarse crackles (chronic bronchitis) or wheezing M odification of skin color from pink to cyanosis in lips, mucous membranes, nail beds (“blue bloaters”) A nteroposterior diameter increased (barrel chest)….emphysema “pink puffers” G ets in the Tripod Position during dyspnea (stands leaning forward while supporting body with hands on knees or an object) E xtreme dyspnea
In turn over time, people with COPD will be stimulated to breathe due to low oxygen levels RATHER than high carbon dioxide levels.
Assessment of COPD Cough Dyspnea/SOB- initial sign Chest pain Sputum production Wheezing Purse lip breathing Alteration in LOC Pallor to cyanosis Cold to touch BARREL CHEST - increase antero-posterior diameter of chest- due to air trapping with diaphragmatic flattening (the classical and late sign of COPD) Clubbing fingers Polcythemia-Patients will have cyanosis due to a decreased oxygen level. To compensate, the body increases RBC production and cause blood to shift elsewhere which increases pressure in the pulmonary artery leading to pulmonary hypertension. Pulmonary hypertension leads to right-sided heart failure
Complications of COPD
Heart Disease (remember heart and lungs work together in replenishing the body with oxygen)…heart failure Pneumothorax (spontaneous due to forming of air sacs) Risk for Pneumonia Cancer (especially lung)
Lab Data: ABG analysis decrease O2 , ph, and increase CO2- Respiratory Acidosis Spirometry
A test where a patient breathes into a tube that measure how much volume the lungs can hold
during inhalation and how much and fast air volume is exhaled. demonstrate airflow obstruction Measuring the FVC (Forced Vital Capacity) : a low reading shows restrictive breathin.It measures the largest amount of air a person exhales after breathing in deeply in one second. Forced Expiratory Volume: measures how much air a person can exhale within one second. A low reading shows the severity of the disease.
Chest X Ray in late stages, hyperinflation, flattened diaphragm, increase retrosternal space, decrease vascular markings Alpha antitrypsin assay to identify genetically determine deficiency in emphysema.
Nsg Diagnosis: Impaired gas exchange/ Ineffective Breathing Pattern/
Nursing Interventions
Assess lung sounds (may need suction) and sputum production…obtain a culture if ordered…at risk for pneumonia Keep the patient in orthopneic position Keep oxygen saturation (88%- 93%). why between this range? Patients with COPD are stimulated to breathe due to LOW OXYGEN SATURATION rather than high carbon dioxide levels….which is the opposite for people for healthy lungs. If they are given too much oxygen it
These inhibit mucociliary function Avoid powerful odors, extreme temperature, pets, fireplace and feather pillows. REST Increase fluid intake Good oral care. Stop smoking or being around people who smoke Vaccination up-to-date: annual flu shot and Pneumovax every 5 years because it is very hard for people with COPD to recover from illnesses Pursed lip and diaphragmatic breathing techniques Administering medications: be familiar with groups, side effects, and patient teaching
Pharmacotherapy
Remember the mnemonic: C hronic P ulmonary M edicati ons S ave L ungs
C orticosteroids: decreases inflammation and mucous production in airway… given: oral, IV, inhaled and used in combination with bronchodilator like:
Symbicort: combination of steroid and long acting bronchodilator Other corticosteroids: Prednisone, Solu-medrol, Pulmicort
Side effects: easy bruising, hyperglycemia, risk of infection, bone problems (long term use) o Patient education: rinse mouth after using inhaled corticosteroids…can develop thrush, use corticosteroid inhaler AFTER using bronchodilator inhaler
M ethylxanthines : Theophylline (most commonly given orally) type of
bronchodilator used long term in patients who have severe COPD
Remember: Narrow therapeutic range of 10 to 20 mcg/mL
Increases risk for digoxin toxicity and decreases the effects of lithium and Dilantin
P hosphodiestrace-4 inhibitors: “Roflumilast” used for people who have chronic bronchitis and it works by decreasing COPD exacerbation…not a bronchodilator
o Side effects: can cause suicidal thoughts (remember the word “last” in the drug’s name…it could be the patient’s last days if they are not assessed for this side effect) and can cause weight loss.
S hort-acting bronchodilators: relaxes the smooth muscle of the bronchial tubes and are used in emergency situations where quick relief is needed
o Albuterol (beta 2 agonist) and Atrovent (anticholinergic) L ong-acting Bronchodilators: relaxes the smooth muscle of the bronchial tubes (same as short-acting bronchodilators BUT their effects last longer) used over a longer period of time….taken once or twice a day
o Beta 2 agonist: salmeterol, anticholinergics: Spiriva o Patient education: let them know which drug is short and long-acting, how to use inhaler and to use bronchodilator inhaler BEFORE steroid inhaler (wait 5 minutes in between)
WHY? TO OPEN UP THE AIRWAYS
SO THE STEROID CAN GET IN THERE
AND DO ITS JOB
o Side effects of beta 2 agonist: increased heart rate, urinary retention o Side effects of anticholinergic: dry mouth, blurred vision
Expectorants/ mucolytic Antitussives - cough suppressant ( best given during the night to prevent sleep pattern disturbance due to persistent coughing) Dextromethorphan codein- SE: drowsiness, constipation BRONCHODILATORS Aminophylline (theophylline)
- indicated for acute exacerbation of asthma or bronchitis -too rapid can cause hypotension, extra systoles, muscle tremors -administer at prescribe rate with infusion pump Ventolin (salbutamol) Bricanyl (Terbutaline) -for acute exacerbation of asthma and bronchitis -maintenance therapy for bronchospasm -prolonged oral used can cause hand tremors -Spiriva ( Tiotropium) -Xopenex (Levalbuterol) -Brethine (Terbutaline) -Alupinol (metaproterenol)
COMMON SIDE EFFECTS :
TACHYCARDIA and PALPITATION Administer bronchodilator inhalation before steroid
inhalation. To open airways and ensure adequate absorption of drugs.
ANTIHISTAMINE
Benadryl (Diphenhydramine) - observe for drowsiness and dizziness. Avoid driving and operating electrical machines to prevent accidents.
STEROIDS
Anti-inflammatory effect (betamethasone, and methylprednisone) Rinse mouth after inhalation to prevent oral thrush (oral moniliasis)
ANTI-MICROBIALS If infection is present
LEUKOTRIENE antagonist Prevent bronchoconstriction, decrease mucosal edema and mucous production. Ex: Montelucast
PLEURISY/PLEURITIS
-inflammation of both parietal and visceral pleura
Pathophysiology
- Inflammation of the pleura stimulates the nerve endings causing PAIN ETILOGY Pneumonia, TB, Pulmonary embolism Pulmonary abscess, URTI Pulmonary neoplasm
CM:
- Pleuritic pain-stabbing pain Chest pain that is severe, sharp and knifelike on inspiration. Localized or radiate to shoulder or abdomen
