BRONCHIAL ASTHMA

 A chronic reactive airway disorder involving episodic, reversible obstruction

resulting from bronchospasms, increased mucus secretions, and mucosal
edema

Causes/Risk Factors:
 Sensitivity to specific external allergens or from internal, none allergenic
factors
Extrinsic Asthma (Atopic Asthma)
• Pollen
• Animal dander
• House dust or mold
• Kapok or feather pillows
• Food additives containing sulfites and any other sensitizing substance

Intrinsic Asthma (Nonatopic Asthma)

• Emotional Stress
• Genetic Factors

Bronchoconstriction
• Hereditary predisposition
• Sensitivity to allergens or irritants such as pollutants
• Viral infections
• Drugs such as aspirin, beta-adrenergic blockers and nonsteroidal
antiinflammatory drugs
• Tartrazine
• Psychological Stress
• Cold air • Exercise

Manifestations
1. Wheezing
2. Shortness of breath, feeling of suffocation
3. Tightness in chest
4. Extrinsic asthma begins in children; commonly accompanied by other
manifestations of atopy
5. Visibly dyspneic
6. Ability to speak only a few words pausing for breath
7. Use of accessory respiratory muscles
8. Diaphoresis
9. Increased anteroposterior thoracic diameter
10. Hyperresonance
11. Tachycardia; tachypnea; mild systolic hypertension
12. Inspiratory and expiratory wheezes
 13. Prolonged expiratory phase of respiration
14. Diminished breath sounds
15. Cyanosis, confusion, and lethargy indicate the onset of life-threatening status
asthmaticus and respiratory failure

Laboratory /Diagnostic Procedures:

1. Arterial Blood Gas (ABG) analysis – it reveals hypoxemia
2. Serum IgE levels - increase from allergic reaction
3. Complete Blood Count (CBC) with Differential Count – it shows increase
eosinophil count
4. Chest X-rays – may show hyperinflation with areas of local atelectasis
5. Pulmonary Function Studies – it may show decreased peak flows and forced
expiratory volume in 1 second, low-normal or decreased vital capacity, and
increased total lung and residual capacities.
6. Skin Testing – it may identify specific allergens
7. Bronchial Challenge Testing – it shows the clinical significance of allergens
identified by skin testing
8. Pulse Oximetry– it may show decreased oxygen saturation

Management:
A. General
1. Identification and avoidance of causes/precipitating/predisposing
factors
2. Desensitization to specific antigens
3. Establishment and maintenance of patent airway
4. Fluid replacement
5. Activity as tolerated

B. Pharmacologic
1. Bronchodilators such as Albuterol, Pirbuterol, Salmeterol, and
Theophylline
2. Corticosteroids
3. Histamine antagonists such as Cetirizine and Diphenhydramine
4. Leukotriene antagonists such as Montelukast, Zafirlukast, and Zileuton
5. Anticholinergic bronchodilators
6. Low-flow oxygen
7. Antibiotics as appropriate
8. Epinephrine
9. Sympathomimetic aerosol sprays

ALERT
The patient with increasingly severe asthma that doesn’t respond to drug
therapy is usually admitted for treatment with corticosteroids,
epinephrine, and sympathomimetic aerosol sprays. He may require
endotracheal intubation and mechanical ventilation.
C. Nursing
Key outcomes
The patient will:
1. Maintain a patent airway
2. Maintain adequate ventilation
3. Use effective coping strategies
4. Report feelings of comfort
5. Maintain skin integrity Nursing Interventions
1. Give prescribed drugs
2. Place the patient in high Fowler’s position
3. Encourage pursed-lip and diaphragmatic breathing
4. Administered prescribed humidified oxygen
5. Adjust oxygen according to the patient’s vital signs and ABG
values
6. Assist with intubation and mechanical ventilation, if
appropriate
7. Perform postural drainage and chest percussion, if tolerated
8. Suction an intubated patient, as needed
9. Treat the patient’s dehydration with I.V. or oral fluids as
tolerated
10. Anticipate bronchoscopy or bronchial lavage
11. Keep the room temperature comfortable
12. Use an air conditioner or a fan in hot, humid weather

Monitoring
1. Vital signs
2. Intake and output
3. Response to treatment
4. Signs and symptoms of theophylline toxicity
5. Breath sounds
6. ABG results
7. Pulmonary functions test results
8. Pulse oximetry
9. Complications of corticosteroids
10. Level of anxiety
Patient Teaching
1. Be sure to cover:
2. the disorder, diagnosis, and treatment
3. medications and potential adverse reactions
4. when to notify the physician
5. avoidance of know allergens and irritants
6. metered-dose inhaler or dry powder inhaler use
7. pursed –lip and diaphragmatic breathing
 8. use of peak flow meter
9. effective coughing techniques
10. maintaining adequate hydration

Discharge Planning
1. Refer the patient to a local support group

CHRONIC OBSTRUCTIVE PULMONARY

DISEASE (COPD)
CHRONIC BRONCHITIS
 An inflammation of the lining of the bronchial tubes characterized by excessive
production of tracheobronchial mucus with a cough for at least 3 months each
year for 2 consecutive years
Causes/Risk Factors:
1. Cigarette smoking
2. Possible genetic predisposition
3. Environmental pollution
4. Organic or inorganic dusts and noxious gas exposure

Manifestations:
1. Frequent upper respiratory tract infection
2. Productive cough
3. Exertional dyspnea
4. Cough producing copious gray, white, or yellow sputum
5. Cyanosis
6. Accessory respiratory muscle tone
7. Tachypnea
8. Substantial weight gain
9. Pedal edema
10. Neck vein distention
11. Wheezing
12. Prolonged expiratory time
13. Rhonchi
Laboratory/Diagnostic Procedures:
1. Arterial Blood Gas – it shows decreased partial pressure of oxygen and
normal or increased partial pressure of carbon dioxide
2. Sputum Culture –it reveals the presence of microorganisms and
neutrophils
3. Chest X-ray – it shows hyperinflation and increased bronchovascular
markings
 4. Pulmonary Function Tests – it shows an increased residual volume,
decreased vital capacity and forced expiratory flow and normal static
compliance and diffusing capacity
5. Electrocardiography (ECG) – it may show atrial arrhythmias; peaked P
waves in leads II, III, and aV ; and right ventricular hypertrophy
F

Management:
General
1. Smoking cessation
2. Avoidance of air pollutants
3. Chest Physiotherapy
4. Ultrasonic or mechanical nebulizer treatments
5. Adequate fluid intake
6. High-calorie, protein –rich diet
7. Activity, as tolerated with frequent rest periods
Pharmacologic
1. Oxygen
2. Bronchodilators
3. Corticosteroids
4. Diuretics
Surgery
1. Tracheostomy in advance diseases

Nursing:
Key Outcomes
The patient will:
1. Maintain adequate ventilation
2. Identify measures to prevent or reduce fatigue
3. Express understanding of the illness
4. Maintain a patent airway

Nursing interventions
1. Give prescribe drug
2. Encourage expression of fears and concerns
3. Include the patient and his family in care decisions
4. Perform chest physiotherapy
5. Provide a high-calorie, protein-rich diet
6. Offer small, frequent meals
7. Encourage energy-conservation techniques
8. Ensure adequate oral fluid intake
9. Provide frequent mouth care
10. Encourage daily activity
11. Provide diversional activities, as appropriate
 12. Provide frequent rest periods

Monitoring
1. Vital signs
2. Intake and output
3. Sputum production
4. Respiratory status
5. Breath sounds
6. Daily weight
7. Edema
8. Response to treatment

Patient Teaching 1.
Be sure to cover:
2. the disorder, diagnosis, and treatment
3. medications and possible adverse reactions
4. when to notify the physician
5. infection control practices
6. influenza and pneumococcus immunizations
7. home oxygen therapy, if required
8. postural drainage and chest percussion
9. coughing and deep-breathing exercise
10. inhaler use
11. high-calorie, protein-rich meals
12. adequate hydration
13. avoidance of inhaled irritants
14. prevention of bronchospasm

Discharge Planning
1. Refer the patient to a smoking-cessation program, if indicated

EMPHYSEMA
 Chronic lung disease characterized by permanent enlargement of air spaces
distal to the terminal bronchioles and by exertional dyspnea

Causes/Risk Factors:
1. Genetic deficiency of alpha - antitrypsin (AAT)
1

2. Cigarette smoking

Manifestations
1. Exertional dyspnea 2.
Chronic cough
3. Shortness of breath
 4. Anorexia and weight loss
5. Malaise
6. Barrel chest
7. Pursed-lip breathing
8. Use of accessory muscles
9. Cyanosis
10. Clubbed fingers and toes
11. Tachypnea
12. Decreased tactile fremitus
13. Decreased chest expansion
14. Hyperresonance
15. Decreased breath sounds
16. Crackles
17. Inspiratory wheeze
18. Prolonged expiratory phase with grunting respirations
19. Distant heart sounds

Laboratory/Diagnostic Procedures:
• Arterial Blood Gas Analysis – it shows a decreased partial pressure of
oxygen, partial pressure of carbon dioxide normal until late in the
disease
• Red Blood Cell Count – it shows an increased hemoglobin level late in
the disease

• Chest X-ray may show:

1. a flattened diaphragm
2. reduced vascular marking at the lung periphery
3. overaeration of the lungs
4. a vertical heart
5. enlarge anteroposterior chest diameter
6. large retrosternal air space

• Pulmonary Function Tests typically show:

 increased residual volume and total lung capacity
 reduced diffusing capacity
 increased inspiratory flow

• Electrocardiography - may show tall, symmetrical P waves in leads II,

III, and aVF; a vertical QRS axis; and signs of right ventricular
hypertrophy late in the disease

Management:
A. General
1. Chest physiotherapy
2. Possible transtracheal catheterization and home oxygen therapy
3. Adequate hydration
 4. High-protein, high-calorie diet
5. Activity, as tolerated

B. Pharmacologic
1. Bronchodilators
2. Anticholinergic
3. Mucolytic
4. Corticosteroids
5. Antibiotics
6. Oxygen

C. Surgery
1. Chest tube insertion for pneumothorax

D. Nursing
Key outcomes
The patient will:
1. Maintain a patent airway and adequate ventilation
2. Demonstrate energy conservation techniques
3. Express understanding of the illness
4. Demonstrate effective coping strategies

Nursing Interventions
1. Give prescribed drugs
2. Provide supportive care
3. Help the patient adjust to lifestyle changes necessitated by a
chronic illness
4. Encourage the patient to express his fears and concerns
5. Perform chest physiotherapy
6. Provide a high-calorie, protein-rich diet
7. Give small, frequent meals
8. Encourage daily activity and diversional activities
9. Provide frequent rest periods
Monitoring
1. Vital signs
2. Intake and output
3. Daily weight
4. Complications
5. Respiratory status
6. Activity tolerance

Patient Teaching
Be sure to cover:
1. the disorder, diagnosis, and treatment
2. medication and potential adverse reactions
 3. when to notify the physician
4. avoidance of smoking and areas where smoking is permitted
5. avoidance of crowds and people with known infections
6. home oxygen therapy, if indicated
7. transtracheal catheter care, if needed
8. coughing and deep-breathing exercise
9. the proper use of handheld inhalers
10. high-calorie, protein-rich diet
11. adequate oral fluid intake
12. avoidance of respiratory irritants
13. signs and symptoms of pneumothorax

Discharge Planning
1. Refer the patient to a smoking –cessation program if indicated.
2. Refer the patient for influenza and pneumococcal pneumonia
immunizations as needed
3. Refer the family of patients with familial emphysema for
alpha1 –antitrypsin deficiency screening

ACUTE RESPIRATORY DISTRESS

SYNDROME/ACUTE LUNG INJURY
 Aka: ARDS, Adult Respiratory Distress Syndrome and shock, stiff,
white, or Da Nang lung.
 A syndrome of altered respiratory function characterized by reduced
perfusion, increased capillary permeability, direct tissue and capillary
injury, and loss of compliance with widespread atelectasis.

Causes:

1. Indirect or direct lung trauma (most common)

2. Anaphylaxis
3. Aspiration of gastric contents
4. Diffuse pneumonia
5. Drug overdose
6. Idiosyncratic drug reaction
7. Inhalation of noxious gases
8. Near-drowning
9. Oxygen toxicity
10. Coronary artery bypass grafting
11. Hemodialysis
12. Leukemia
13. Acute military tuberculosis
14. Pancreatitis
15. Thrombotic thrombocytopenic purpura
 16. Uremia
17. Venous air embolism

ASSESSMENT
History
1. Causative factor (one or more)
2. Dyspnea, especially on exertion

Physical findings

Stage I
1. Shortness of breath, especially on exertion
2. Normal to increased respiratory and pulse rates
3. Diminished breath sounds

Stage II
1. Respiratory distress
2. Use of accessory muscles for respiration
3. Pallor, anxiety, and restlessness
4. Dry cough with thick, frothy sputum
5. Bloody, sticky secretions
6. Cool, clammy skin
7. Tachycardia and tachypnea
8. Elevated blood pressure
9. Basilar crackles

Stage III
1. Respiratory rate greater than 30 breaths/minute
2. Tachycardia with arrhythmias
3. Labile blood pressure
4. Productive cough
5. Pale, cyanotic skin
6. Crackles and rhonchi possible

Stage IV
1. Acute respiratory failure with severe hypoxia
2. Deteriorating mental status (may become comatose)
3. Pale, cyanotic skin
4. Lack of spontaneous respirations
5. Bradycardia with arrhythmias
6. Hypotension
7. Metabolic and respiratory acidosis
Diagnostic Assessment

Laboratory
1. ABG analysis – initially shows a reduced partial pressure of
arterial oxygen (PaO2) less than 60 mmHg and a decreased partial
pressure of arterial carbon dioxide (PaCO2) which is less than 35
mmHg.
- Later shows increased PaCO2 of more than 45
mmHg and decreased bicarbonate levels less than
22 mEq/L and decreased PaO2 despite oxygen
therapy.
2. Gram stain and sputum culture and sensitivity – shows infectious
organism
3. Blood cultures – reveals infectious organism
4. Toxicology test – shows drug ingestion in overdose
5. Serum amylase – levels are increased in pancreatitis

Imaging
1. Chest X-rays may show early bilateral infiltrates; in later stages, a
ground glass appearance and, eventually whiteouts of both lung
fields.

Others
1. Pulmonary artery catheterization – may show a pulmonary artery
wedge pressure of 12 to 18 mmHg.

Nursing Diagnoses
1. Impaired gas exchange
2. Ineffective breathing pattern
3. Decrease cardiac output
4. Inability to sustain spontaneous ventilation
5. Altered tissue perfusion, cardiopulmonary
6. Altered nutrition less than body requirement
7. Activity intolerance
8. Dysfunction ventilatory weaning response
9. Powerlessness
10. Hopelessness
11. Fear
12. Sensory/perceptual alterations (olfactory)
13. Ineffective individual coping
14. Anxiety

Planning
Implementation
General Management
1. Treatment of the underlying cause
2. Correction of electrolyte and acid base imbalances
For mechanical ventilation
3. Target low tidal volumes; use of increase respiratory rates
4. Target plateau pressures less than equal to 40 cm H2O
5. Positive end-expiratory pressure (PEEP) as necessary
6. Fluid restriction
7. Tube findings or parenteral nutrition
8. Bed rest

Medications
1. Humidified oxygen
2. Bronchodilators, such as albuterol and theophylline
3. Diuretics, such as furosemide and torsemide
For mechanical ventilation
4. Sedatives
5. Opioids
6. Neuromuscular blockers
7. Short course of high- dose corticosteroids if fatty emboli oe
chemical injury
8. Sodium bicarbonate if severe metabolic acidosis
9. Fluids and vasopressors if hypotensive
10. Antimicrobials, as appropriate, for nonviral infection

Surgery
Possible tracheostomy

Nursing
Key outcomes
The patient will:
1. Maintain adequate ventilation
2. Maintain a patent airway
3. Use effective coping strategies
4. Maintain skin integrity
5. Report feelings of increased comfort

Nursing interventions
1. Give prescribe drugs
2. Maintain a patent airway
3. Perform tracheal suctioning, as necessary
4. Ensure adequate humidification
5. Reposition the patient often
6. Consider prone positioning for alveolar recruitment
 7. Administer tube feedings or parenteral nutrition, as ordered.
8. Allow periods of uninterrupted sleep
9. Perform passive range-of-motion exercise
10. Provide meticulous skin care
11. Reposition the endotracheal (ET) tube per facility policy
12. Provide emotional support
13. Provide alternative communication means.

Monitoring
1. Vital signs and pulse oximetry
2. Hemodynamics
3. Intake and output
4. Respiratory status (breath sounds, ABG results)
5. Mechanical ventilator settings
6. Sputum characteristics
7. Level of consciousness
8. Daily weight
9. Laboratory studies
10. Response to treatment
11. Complications, such as cardiac arrhythmias, DIC, GI bleeding,
infection, malnutrition, or pneumothorax
12. Nutritional status

Patient Teaching
Be sure to cover:
1. the disorder, diagnosis, and treatment
2. medications and possible adverse reactions
3. when to notify the physician
4. complications, such as GI bleeding, infection, and malnutrition
5. recovery time

Discharge planning

1. Refer the patient to a pulmonary rehabilitation program, if

indicated.