Acute Respiratory Distress Syndrome

- ARDS can be thought of as a spectrum of disease, from its milder form (acute lung
injury) to its most severe form of fulminate, life-threatening ARDS.

Risk Factor
● Aspiration (gastric secretions, drowning, hydrocarbons)
● Drug ingestion and overdose
● Hematologic disorders (disseminated intravascular coagulopathy, massive transfusions,
cardiopulmonary bypass)
● Prolonged inhalation of high concentrations of oxygen, smoke, or corrosive substances
● Localized infection (bacterial, fungal, viral pneumonia)
● Metabolic disorders (pancreatitis, uremia)
● Shock (any cause)
● Trauma (pulmonary contusion, multiple fractures, head injury)
● Major surgery Fat or air embolism Sepsis

Pathophysiology
Inflammatory triggers initiate the release of cellular and chemical mediators, causing injury to
the alveolar capillary membrane in addition to other structural damage to the lungs. Severe V./Q.
mismatching occurs. Alveoli collapse because of the inflammatory infiltrate, blood, fluid, and
surfactant dysfunction. Small airways are narrowed because of interstitial fluid and bronchial
obstruction. Lung compliance may markedly decrease, resulting in decreased functional residual
capacity and severe hypoxemia. The blood returning to the lung for gas exchange is pumped
through the non ventilated, non functioning areas of the lung, causing shunting. This means that
blood is interfacing with nonfunctioning alveoli and gas exchange is markedly impaired,
resulting in severe, refractory hypoxemia.
Clinical Manifestations
● severe dyspnea
● Arterial hypoxemia

Assessment and Diagnostic Findings

● physical examination
● e plasma brain natriuretic peptide (BNP) levels
● echocardiography, and
● pulmonary artery catheterization

Medical Management
● identification and treatment of the underlying condition
● endotracheal intubation and mechanical ventilation
● circulatory support, adequate fluid volume, and nutritional support
● Supplemental oxygen
● ventilatory PEEP support
● Inotropic or vasopressor agents

Pharmacologic Therapy
● Neuromuscular blocking agents, sedatives, and analgesics
● Inhaled nitric oxide

Nutritional Therapy
● require 35 to 45 kcal/kg/day to meet caloric requirements

Nursing Management
● Frequent assessment of the patient’s status
● Positioning. Turns the patient frequently to improve ventilation and perfusion in the lungs
and enhance secretion drainage
● Reduce the patient’s anxiety
● Rest is essential to limit oxygen consumption and reduce oxygen needs.

Chronic Obstructive Pulmonary Disease

- COPD may include diseases that cause airflow obstruction (e.g., emphysema, chronic
bronchitis) or any combination of these disorders. Other diseases such as cystic fibrosis
(CF), bronchiectasis, and asthma are classified as chronic pulmonary disorders.

Pathophysiology
In COPD, the airflow limitation is both progressive and associated with the lungs’ abnormal
inflammatory response to noxious particles or gases. The inflammatory response occurs
throughout the proximal and peripheral airways, lung parenchyma, and pulmonary vasculature .
Because of the chronic inflammation and the body’s attempts to repair it, changes and narrowing
occur in the airways. In the proximal airways (trachea and bronchi greater than 2 mm in
diameter), changes include increased numbers of goblet cells and enlarged submucosal glands,
both of which lead to hypersecretion of mucus. In the peripheral airways (bronchioles less than 2
mm diameter), inflammation causes thickening of the airway wall, peribronchial fibrosis,
exudate in the airway, and overall airway narrowing (obstructive bronchiolitis). Over time, this
ongoing injury-and-repair process causes scar tissue formation and narrowing of the airway
lumen. Inflammatory and structural changes also occur in the lung parenchyma (respiratory
bronchioles and alveoli). Alveolar wall destruction leads to loss of alveolar attachments and a
decrease in elastic recoil. Finally, the chronic inflammatory process affects the pulmonary
vasculature and causes thickening of the lining of the vessel and hypertrophy of smooth muscle,
which may lead to pulmonary hypertension.
Risk Factors
● cigarette smoking (most common)
● smoking pipes, cigars, and other types of tobacco
● Passive smoking (i.e., secondhand smoke)
● Increased age
● Occupational exposure—dust, chemicals
● Indoor and outdoor air pollution
● Genetic abnormalities, including a deficiency of alpha1-antitrypsin

Clinical Manifestations
● chronic cough, sputum production, and dyspnea (primary symptoms)
● Weight loss
● “barrel chest” thorax configuration

Assessment and Diagnostic Findings

● Pulmonary function studies
● Spirometry
● Chest x-ray
● computed tomography (CT) chest scan
● screening for alpha1-antitrypsin deficiency

Complications
● Respiratory insufficiency and failure (major life-threatening complications of COPD)
● Pneumonia
● chronic atelectasis
● pneumothorax, and
● pulmonary arterial hypertension
● Cor Pulmonale

Medical Management
 ● promoting smoking cessation
● Bronchodilators
● Corticosteroids
● providing supplemental oxygen therapy

Pharmacologic Therapy
● For grade I (mild) COPD, a short-acting bronchodilator may be prescribed
● For grade II or III COPD, a short-acting bronchodilator and regular treatment with one or
more long-acting bronchodilators may be used
● For grade III or IV (severe or very severe) COPD, regular treatment with one or more
bronchodilators and/or inhaled corticosteroids for repeated exacerbations.

Surgical Management
● Bullectomy
● Lung Volume Reduction Surgery
● Lung Transplantation

Nursing Management
● Assessing the Patient
● Achieving Airway Clearance
● Improving Breathing Patterns
● Improving Activity Tolerance
● Monitoring and Managing Potential Complications

TYPES OD COPD

CHRONIC BRONCHITIS
- Results from inflammation of the bronchi, leading to increased production of mucus,
chronic cough and eventual scarring of the bronchial lining.

Risk Factors
- smoke or other environmental pollutants

Signs and Symptoms

- cough
- increase sputum production
- dyspnea
- wheezing

Diagnostic test
- Chest X-ray
- Sputum exam analysis

Complication
- Respiratory Infection

EMPHYSEMA
- an abnormal distention of the airspaces beyond the terminal bronchioles and destruction
of the walls of the alveoli
- In emphysema, impaired oxygen and carbon dioxide exchange results from destruction of
the walls of over distended alveoli.
Risk Factors
- Environmental exposure
- Cigarette Smoking
- Second hand smoke
Signs
- Hypoxemia
- Hypercapnia
- Barrel Chest
- Frequent coughing and wheezing
- Dyspnea
- A cough that produces a lot of mucus

Diagnostic test
- Chest X-ray
- Arterial blood gas analysis

Complications
- COR Pulmonale
- Right sided heart failure
- Respiratory Acidosis
- Pulmonary hypertension

Two TYPES of Emphysema

1) Panlobular (Panacinar) Emphysema - there is destruction of the respiratory bronchiole,
alveolar duct, and alveolus. All airspaces within the lobule are essentially enlarged, but
there is little inflammatory disease.

2) Centrilobular (Centroacinar) Emphysema - pathologic changes take place mainly in

the center of the secondary lobule, preserving the peripheral portions of the acinus. There
is a derangement of ventilation–perfusion ratios, producing chronic hypoxemia,
hypercapnia, polycythemia and episodes of right-sided heart failure. This leads to central
cyanosis and respiratory failure. The patient also develops peripheral edema.

ASTHMA
- is a heterogeneous disease, usually characterized by chronic airway inflammation.

Pathophysiology
Clinical Manifestations
● Cough
● Dyspnea
● Wheezing
● cough, with or without mucus production
● Diaphoresis
● Tachycardia
● widened pulse
● Hypoxia
● Cyanosis

Assessment and Diagnostic Findings

● positive family history and environmental factors
● sputum and blood tests
● Serum levels of IgE
● Arterial blood gas analysis

Prevention
● undergo tests to identify the substances that precipitate the symptoms
● Patients are instructed to avoid the causative agents whenever possible
● Knowledge is the key to quality asthma care

Complications
● status asthmaticus
● respiratory failure
● Pneumonia
● Atelectasis
Medical Management
Quick-Relief Medications
● Short-acting beta2-adrenergic agonists (SABA) (e.g., albuterol, levalbuterol, pirbuterol,
Anticholinergics
● Anticholinergics (e.g., ipratropium [Atrovent])
Long-Acting Control Medications
● Corticosteroids
● Cromolyn sodium (Crolom, NasalCrom) and nedocromil (Alocril, Tilade)
● Long-acting beta2-agonists (LABA) (e.g., Theophylline, Salmeterol (Serevent Diskus)
and formoterol (Foradil Aerolizer)
● Leukotriene modifiers (inhibitors), or antileukotrienes
● Immunomodulators

Nursing Management
● assesses the patient’s respiratory status by monitoring the severity of symptoms, breath
sounds, peak flow, pulse oximetry, and vital signs.
● Obtains a history of allergic reactions to medications before administering medications.
Identifies medications the patient is taking.
● Administers medications as prescribed and monitors the patient’s responses to those
medications
● Administers fluids if the patient is dehydrated.

COMPLICATION OF COPD
 Cor PULMONALE
- “heart of the lungs”
- a condition that results from PH, which causes the right side of the heart to enlarge
because of the increased work required to pump blood against high resistance through the
pulmonary vascular system.

Bronchiectasis
- is a chronic, irreversible dilation of the bronchi and bronchioles that results from
destruction of muscles and elastic connective tissue.
Risk Factors
- recurrent respiratory infections
- CF
- rheumatic and other systemic diseases
- primary ciliary dysfunction
- tuberculosis
- immunodeficiency disorders
Signs and Symptoms
- Chronic cough
- Purulent sputum in copious amounts
- Hemoptysis
- Clubbing of fingers
- Episodes of pulmonary infection
Assessment and Diagnostic Findings
- CT scan
- Prolonged history of productive, chronic cough, with sputum
Management
- Postural drainage
- Bronchoscopy
 - Chest physiotherapy
Medical Management
- Antibiotics
- Antimicrobial therapy (broad-spectrum antibiotics)
- Bronchodilators
- Nebulized mucolytics

Surgical Management
- Segmental resection
- Lobectomy
- Pneumonectomy
Complications
- Atelectasis
- Pneumonia
- Broncho pleural fistula
- Empyema
Nursing Management
- Alleviate symptoms
- Ensure adequate hydration and employ physiotherapy
- Educate patient in eliminating smoking and other factors
- Patient and families are taught to perform postural drainage and avoid infections

Respiratory failure
is a sudden and life-threatening deterioration of the gas exchange function of the lung and
indicates failure of the lungs to provide adequate oxygenation or ventilation for the blood.

Acute Respiratory Failure

- Acute respiratory failure is defined as a decrease in arterial oxygen tension (PaO2) to less
than 60 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2)
to greater than 50 mm Hg (hypercapnia), with an arterial pH of less than 7.35.

Pathophysiology
In acute respiratory failure, the ventilation or perfusion mechanisms in the lung are impaired.
Ventilatory failure mechanisms leading to acute respiratory failure include impaired function of
the central nervous system (i.e., drug overdose, head trauma, infection, hemorrhage, and sleep
apnea), neuromuscular dysfunction (i.e., myasthenia gravis, Guillain–Barré syndrome,
amyotrophic lateral sclerosis, and spinal cord trauma), musculoskeletal dysfunction (i.e., chest
trauma, kyphoscoliosis, and malnutrition), and pulmonary dysfunction (i.e., COPD, asthma, and
cystic fibrosis).
Oxygenation failure mechanisms leading to acute respiratory failure include pneumonia, acute
respiratory distress syndrome (ARDS), heart failure, COPD, PE, and restrictive lung diseases
(diseases that cause decrease in lung volumes).

Clinical Manifestations
● Early signs associated w/ impaired oxygenation
- restlessness
- fatigue
- headache
- dyspnea
- air hunger
- tachycardia, and
 - increased blood pressure
● Progression of hypoxia
- confusion
- lethargy
- tachycardia
- tachypnea
- central cyanosis
- diaphoresis, and
- finally respiratory arrest.

Medical Management
● Correct the underlying cause
● Restore adequate gas exchange in the lung
● Endotracheal intubation and mechanical ventilation

Nursing Management
● assesses the patient’s respiratory status
● monitoring the level of responsiveness, arterial blood gases, pulse oximetry, and vital
signs.
● Prevent complications
● provides education as appropriate to address the disorder.