Respiratory

disease
 Respiratory system
• Is composed of structures involved the physical movement of air into and out of
the lungs and in gas exchange.
 Functions of Respiratory system:
1. Providing a large area for gas exchange between air and circulating blood.
2. Moving air to and from gas exchange surfaces of the lungs
3. Protecting the respiratory surfaces from dehydration and temperature
changes and defending against invading pathogens.
4. Producing sound permitting speech, singing and other forms of
communication
5. Aiding the sense of smell by the olfactory receptors in the nasal cavity
Components of the respiratory system
Respiratory changes in older adults
• Increase in residual volume
• Decrease in muscle strength, endurance and vital
capacity
• Decrease gas exchange and diffusing capacity
• Decrease cough efficiency
Respiratory diseases
common to the aged
 Chronic Obstructive Pulmonary disease
(COPD)
• Commonly known now as Chronic Airway Limitation
(CAL)
• Is commonly used when person has both Emphysema
and Chronic Bronchitis
• Common in older adult at ages 50 to 60
Chronic Obstructive Pulmonary Disease (COPD)
COPD is a disease characterized by airflow limitation that is not fully
reversible. The airflow limitation is usually progressive and associated
with an abnormal inflammatory response of the lung to noxious particles
or gases, resulting in narrowing of airways, hypersecretion of mucus, and
changes in thepulmonary vasculature. Other diseases such as cystic
fibrosis,bronchiectasis, and asthma that were previously classified as
types of COPD are now classified as chronic pulmonary disorders,
although symptoms may overlap with those of COPD.
Cigarette smoking, air pollution, and occupational exposure (coal, cotton,
grain) are important risk factors that contribute to COPD development,
which may occur over a 20- to 30-year span. Complications of COPD
vary but include respiratory insufficiency and failure (major
complications) as well as pneumonia, atelectasis, and
pneumothorax.
Clinical Manifestations
>COPD is characterized by chronic cough,
>sputum production,
>dyspnea on exertion
>Weight loss is common.
Gerontologic Considerations
COPD accentuates many of the physiologic changes associated
With aging and is manifested in airway obstruction (in
bronchitis) and excessive loss of elastic lung recoil (in
emphysema).Additional changes in ventilation–perfusion ratios
occur
Medical Management
>Smoking cessation,
>Bronchodilators (beta agonists such as salbutamol salmeterol)
>Corticosteroids (cortisone prednisone, dexamethasone betamethasone)
other drugs (eg,alpha1-antitrypsin augmentation therapy, antibiotic
agents,mucolytic agents, antitussive agents, vasodilators,
narcotics). >Oxygen therapy,
>Surgery: bullectomy surgical removal of bulla-dilated air space
>lung transplant
Nursing Management
>Assessment
Obtain information about current symptoms as well as previous disease
manifestations. In addition to the history, nurses review the results of
available diagnostic tests.
>Achieving Airway Clearance.
Monitor the patient for dyspnea and hypoxemia.
>Encourage patient to eliminate or reduce all pulmonary irritants,
particularly cigarette smoking.
>>Instruct the patient in controlled coughing.
>Chest physiotherapy with postural drainage,
>Intermittent positive-pressure breathing,
>increased fluid intake, and bland aerosol mists.
>Inspiratory muscle training and breathing retraining
>Training in diaphragmatic breathing r
>Pursed-lip breathing
Improving Activity Tolerance
• Evaluate the patient’s activity tolerance and limitations and
use teaching strategies to promote independent activities of
daily living.
• Determine if patient is a candidate for exercise training to
strengthen the muscles of the upper and lower extremities
and to improve exercise tolerance and endurance.
• Recommend use of walking aids, if appropriate, to improve
activity levels and ambulation.
• Consult with other health care professionals (rehabilitation
therapist, occupational therapist, physical therapist) as
needed.
Monitoring and Managing Complications
• Assess patient for complications (respiratory insufficiency and failure,
respiratory infection, and atelectasis).
• Monitor for cognitive changes, increasing dyspnea, tachypnea, and
tachycardia.
• Monitor pulse oximetry values and administer oxygen as prescribed.
• Instruct patient and family about signs and symptoms of infection or other
complications and to report changes in physical or cognitive status.
• Encourage patient to be immunized against influenza and Streptococcus
pneumonia.
• Caution patient to avoid going outdoors if the pollen count is
high or if there is significant air pollution and to avoid exposure
to high outdoor temperatures with high humidity.
• If a rapid onset of shortness of breath occurs, quickly evaluate
the patient for potential pneumothorax by assessing the symmetry
of chest movement, differences in breath sounds, and pulse
oximetry
 Chronic bronchitis
• Is a form of COPD emphasized by chronic cough
• Cough up sputum during morning
• This happened because mucus glands in the airway
increases output and patient have to cough that extra
secretion out
• Same way of treatment to COPD
Bronchitis, Chronic
• Chronic bronchitis, a disease of the airways, is defined as the presence of
cough and sputum production for at least 3 months in each of two
consecutive years. Although, chronic bronchitis is a clinically and
epidemiologically useful term, it does not reflect the major impact of
airflow limitation on morbidity and mortality in COPD. In many cases,
smoke or other environmental pollutants irritate the airways, resulting in
inflammation and hypersecretion of mucus.
• Constant irritation causes the mucus-secreting glands and
goblet cells to increase in number, leading to increased mucus
production. Mucus plugging of the airway reduces ciliary
function. Bronchial walls also become thickened, further
narrowing the bronchial lumen. Alveoli adjacent to the
bronchioles may become damaged and fibrosed, resulting in
altered function of the alveolar macrophages. This is significant
because the macrophages play an important role in destroying
foreign particles, including bacteria.
People may be predisposed to bronchiectasis as a result of recurrent
respiratory infections in early childhood, measles, influenza, tuberculosis,
or immunodeficiency disorders.
Clinical Manifestations Chronic cough and production of copious purulent
sputum Hemoptysis, clubbing of the fingers, and repeated episodes of
pulmonary infection Assessment and Diagnostic Findings Definite
diagnostic clue is prolonged history of productive cough, with sputum
consistently negative for tubercle bacilli.
Diagnosis is established on the basis of CT scan.
• Medical Management Treatment objectives are to promote
bronchial drainage to clear excessive secretions from the
affected portion of the Lungs and to prevent or control
infection. Chest physiotherapy with percussion; postural
drainage, expectorants, or bronchoscopy to remove bronchial
secretions.
 Antimicrobial therapy guided by sputum sensitivity studies. B Year-round
regimen of antibiotics, alternating types of drugsat intervals.
• Vaccination against influenza and pneumococcal pneumonia.
• Bronchodilators.
• Smoking cessation.
• Surgical intervention (segmental resection of lobe or lung
removal), used infrequently.
• In preparation for surgery: vigorous postural drainage, suction through
bronchoscope, and antibacterial therapy
Pneumothorax and Hemothorax
Pneumothorax occurs when the parietal or visceral pleura is
breached and the pleural space is exposed to positive atmospheric
pressure. Normally the pressure in the pleural space is negative or
subatmospheric; this negative pressure is required to maintain lung
inflation. When either pleura is breached, air enters the pleural
space, and the lung or a portion of it collapses. Hemothorax is the
collection of blood in the chest cavity because of torn intercostal
vessels or laceration of the lungs injured through trauma. Often both
blood and air are found in the chest cavity (hemopneumothorax).
Types of Pneumothorax
Simple Pneumothorax
A simple, or spontaneous, pneumothorax occurs when air enters the pleural
space through a breach of either the parietal or visceral pleura. Most
commonly this occurs as air enters the pleural space through the rupture of
a bleb or a bronchopleural fistula.
Spontaneous pneumothorax may occur in an apparently healthy person in
the absence of trauma due to rupture of an air-filled bleb, or blister, on the
surface of the lung, allowing air from the airways to enter the pleural
cavity. It may be associated with diffuse interstitial lung disease and
severe emphysema.
Traumatic Pneumothorax
A traumatic pneumothorax occurs when air escapes from a laceration in the
lung itself and enters the pleural space or from a wound in the chest wall. It
may result from blunt trauma (eg, rib fractures), penetrating chest or
abdominal trauma (eg, stab wounds or gunshot wounds), or diaphragmatic
tears. Traumatic pneumothorax may occur during invasive thoracic
procedures (ie, thoracentesis, transbronchial lung biopsy, insertion of a
subclavian line) in which the pleura is inadvertently punctured, or with
barotrauma from mechanical ventilation.
• A traumatic pneumothorax resulting from major injury to the
chest is often accompanied by hemothorax. Open
pneumothorax is one form of traumatic pneumothorax. It
occurs when a wound in the chest wall is large enough to allow
air to pass freely in and out of the thoracic cavity with Peach
attempted respiration.
NURSING ALERT
Traumatic open pneumothorax calls for emergency interventions. Stopping
the flow of air through the opening in thechest wall is a life-saving
measure.
Tension Pneumothorax A tension pneumothorax occurs when air is drawn
into the pleural space and is trapped with each breath. Tension builds up in
the pleural space, causing lung collapse. Mediastinal shift (shift of the heart
and great vessels and trachea toward the unaffected side of the chest) is a
life-threatening medical emergency. Both respiratory and circulatory
functions are compromised
Clinical Manifestations
• Pleuritic pain of sudden onset.
• Minimal respiratory distress with small pneumothorax;
• Acute respiratory distress if large.
• Anxiety,
• dyspnea,
• air hunger,
• use of accessory muscles,
• central cyanosis (with severe hypoxemia).
• In a simple pneumothorax, the trachea is midline, expansion of
the chest is decreased, breath sounds may be diminished, and
percussion of the chest may reveal normal sounds or
hyperresonance depending on the size of the pneumothorax. In
a tension pneumothorax, the trachea is shifted away from the
affected side, chest expansion may be decreased or fixed in a
hyperexpansion state, breath sounds are diminished or absent,
and percussion to the affected side is hyperresonant.
The clinical picture is one of air hunger, agitation, increasing hypoxemia,
central cyanosis, hypotension, tachycardia,and profuse diaphoresis.
Medical Management .
• The goal is evacuation of air or blood from the pleural space.
• A small chest tube is inserted near the second intercostal space for a
pneumothorax.
• A large-diameter chest tube is inserted, usually in the fourth or fifth
intercostal space, for hemothorax.
• Autotransfusion is begun if excessive bleeding from chest tube occurs.
• Traumatic open pneumothorax is plugged (petroleum gauze); patient is
asked to inhale and strain against a closed glottis to eject air from the
thorax until the chest tube is inserted, with water-seal drainage.
• An emergency thoracotomy may also be performed in the emergency
department if a cardiovascular injury secondary to chest or penetrating
trauma is suspected. The patient with a possible tension pneumothorax
should immediately be given a high concentration of supplemental
oxygen to treat the hypoxemia, and pulse oximetry should be used to
monitor oxygen saturation.
 In an emergency situation, a tension pneumothorax can be decompressed
or quickly converted to a simple pneumothorax by inserting a large-bore
needle (14-gauge) at the second intercostal space, midclavicular line on the
affected side. A chest tube is then inserted and connected to suction to
remove the remaining air and fluid, reestablish the negative pressure, and
reexpand the lung.
 Nursing Management
• Promote early detection through assessment and identification of high-
risk population; report symptoms.
• Assist in chest tube insertion; maintain chest drainage or water-seal.
• Monitor respiratory status and reexpansion of lung, with interventions
(pulmonary support) performed in collaboration with other health care
professionals (eg, physician, respiratory therapist, physical therapist).
• Provide information and emotional support to patient and family.
Pulmonary Embolism
• PE refers to the obstruction of the pulmonary artery or
one of its branches by a thrombus (or thrombi) that
originates somewhere in the venous system or in the right
side of the heart.Gas exchange is impaired in the lung
mass supplied by the obstructed vessel. Massive PE is a
life-threatening emergency;death commonly occurs within
1 hour after the onset of symptoms. It is a common
disorder associated with trauma, surgery (orthopedic,
major abdominal, pelvic, gynecologic), pregnancy, HF,
age more than 50 years,
• hypercoagulable states, and prolonged immobility. It also
may occur in apparently healthy people. Most thrombi
originate in the deep veins of the legs.
Clinical Manifestations
>Dyspnea is the most common symptom.
>Tachypnea is the most frequent sign.
>Chest pain is common, usually sudden in onset and
pleuritic in nature;
Anxiety, fever, tachycardia, apprehension, cough,
diaphoresis, hemoptysis, syncope, shock, and sudden
death may occur.
Initial diagnostic chest x-ray, ECG, ABG analysis, and
ventilation–perfusion scan. •
Pulmonary angiography is considered the best method to
diagnose PE; however, it may not be feasible, cost-
effective, or easily performed, especially with critically ill
patients. • Spiral CT scan of the lung, D-dimer assay (blood
test for evidence of blood clots), and pulmonary arteriogram
may be warranted.
Prevention
• Ambulation or leg exercise in patients on bed rest
• Application of sequential compression devices
• Anticoagulant therapy for patients whose hemostasis is
adequate and who are undergoing major elective abdominal
or thoracic surgery
Medical Management
• Immediate objective is to stabilize the cardiopulmonary
system.Nasal oxygen is administered immediately to
relieve hypoxemia, respiratory distress, and central
cyanosis.
• IV infusion lines are inserted to establish routes for
medications or fluids that will be needed.
• A perfusion scan, hemodynamic measurements, and ABG
• determinations are performed. Spiral (helical) CT or
• pulmonary angiography.
• Hypotension is treated by a slow infusion of dobutamine
(Dobutrex), which has a dilating effect on the pulmonary vessels and
bronchi, or dopamine (Intropin).
• The ECG is monitored continuously for dysrhythmias and right
ventricular failure, which may occur suddenly.
• Digitalis glycosides, IV diuretics, and antiarrhythmic agents are
administered when appropriate.
• Blood is drawn for serum electrolytes, complete blood cell count,
and hematocrit.
• If clinical assessment and ABG analysis indicate the
need, the patient is intubated and placed on a mechanical
ventilator.
• •If the patient has suffered massive embolism and is
hypotensive, an indwelling urinary catheter is inserted to
monitor urinary output.
• Small doses of IV morphine or sedatives are administered
to relieve patient anxiety, to alleviate chest discomfort, to
improve tolerance of the endotracheal tube, and to ease
adaptation to the mechanical ventilator.
• Anticoagulation Therapy
(heparin, warfarin sodium [Coumadin]) has traditionally
been the primary method for managing acute DVT and PE
(numerous specific options for treatment are available).
• continue to take some form of anticoagulation for at least
3 to 6 months after the embolic event.
• Major side effects are bleeding anywhere in the body and
anaphylactic reaction resulting in shock or death. Other
sideeffects include fever, abnormal liver function, and
allergic skin reaction.
Thrombolytic therapy
may include urokinase, streptokinase,and alteplase. affecting a
significant area and causing hemodynamic instability.
• Bleeding is a significant side effect; nonessential invasive
procedures are avoided.
Surgical Management
• • A surgical embolectomy is rarely performed but may be indicated
if the patient has a massive PE or hemodynamic instability or if
there are contraindications to thrombolytic therapy.Transvenous
catheter embolectomy with or without insertion of an inferior vena
caval filter (eg, Greenfield).
Nursing Management
• Minimizing the Risk of PE
• The nurse must have a high degree of suspicion for PE in all
patients, but particularly in those with conditions predisposing to
a slowing of venous return.
• Preventing Thrombus Formation
• Encourage early ambulation and active and passive leg
exercises.Instruct patient to move legs in a “pumping” exercise.
Advise patient to avoid prolonged sitting, immobility, and
constrictive clothing.
• Do not permit dangling of legs and feet in a dependent
position. Instruct patient to place feet on floor or chair and
to avoid crossing legs. Do not leave IV catheters in veins
for prolonged periods.
• Monitoring Anticoagulant and Thrombolytic Therapy
• Advise bed rest, monitor vital signs every 2 hours, and
limit invasive procedures.
• Measure international normalized ratio (INR) or activated
partial thromboplastin time (PTT) every 3 to 4 hours after
• thrombolytic infusion is started to confirm activation of
fibrinolytic systems.
• Perform only essential ABG studies on upper extremities,
with manual compression of puncture site for at least 30
minutes.
• Minimizing Chest Pain, Pleuritic
• Place patient in semi-Fowler’s position; turn and
reposition frequently.
• Administer analgesics as prescribed for severe pain.
• Managing Oxygen Therapy
• Assess the patient frequently for signs of hypoxemia and
monitors the pulse oximetry values
• Assist patient with deep breathing and incentive spirometry.
• Nebulizer therapy or percussion and postural drainage maybe
necessary for management of secretions.
• Alleviating Anxiety
• Encourage patient to express feelings and concerns.
• Answer questions concisely and accurately.
• Explain therapy, and describe how to recognize untoward effects
Monitoring for Complications
• Be alert for the potential complication of cardiogenic
shock or right ventricular failure subsequent to the effect
of PE on the cardiovascular system.
Providing Postoperative Nursing Care
• Measure pulmonary arterial pressure and urinary output.
• Assess insertion site of arterial catheter for hematoma
formation and infection.
• Maintain blood pressure to ensure perfusion of vital organs.
• Encourage isometric exercises, antiembolism stockings, and
• walking when permitted out of bed; elevate foot of bed when
patient is resting.
• Discourage sitting; hip flexion compresses large veins in the legs.
• Promoting Home- and Community-Based Care
Teaching Patients Self-Care
• Before discharge and at follow-up clinic or home visits, teach
• patient how to prevent recurrence and which signs and symptoms
should alert patient to seek medical attention.
• Teach patient to look for bruising and bleeding when
taking anticoagulants and to avoid bumping into objects.
• Advise patient to use a toothbrush with soft bristles to
prevent gingival bleeding.
• Instruct patient not to take aspirin (an anticoagulant) or
antihistamine drugs while taking warfarin sodium
(Coumadin).
• Advise patient to check with physician before taking any
medication, including OTC drugs.
• Advise patient to continue wearing antiembolism stockings as long as
directed
• Instruct patient to avoid laxatives, which affect vitamin K absorption (vitamin
K promotes coagulation).
• • Teach patient to avoid sitting with legs crossed or for prolonged periods.
• • Recommend that patient change position regularly when traveling, walk
occasionally, and do active exercises of legs and ankles.
• Advise patient to drink plenty of liquids.
• Teach patient to report dark, tarry stools immediately.
• Recommend that patient wear identification stating that he or she is taking
anticoagulants.
 Pleural Effusion
a collection of fluid in the pleural space, is usually secondary to
other diseases (eg, pneumonia, pulmonary
infections, nephrotic syndrome, connective tissue disease,
neoplastic tumors, congestive HF). The effusion can be relatively
clear fluid (a transudate or an exudates) or it can be blood or pus.
Pleural fluid accumulates due to an imbalance in hydrostatic or
oncotic pressures (transudate) or as a result of inflammation by
bacterial products or tumors (exudate).
 Clinical Manifestations
Symptoms
are caused by the underlying disease. Pneumonia causes fever,
chills, and pleuritic chest pain. Malignant effusion may result in
dyspnea and coughing. The size of the effusion, the speed of its
formation, and the underlying lung disease determine the severity of
symptoms.
Large effusion: shortness of breath to acute respiratory distress.
Small to moderate effusion: Dyspnea may not be present.
Dullness or flatness to percussion over areas of fluid, minimal or
absence of breath sounds, decreased fremitus, and tracheal
deviation away from the affected side.
 treatment modalities
• Include surgical pleurectomy
• or implantation of a pleuroperitoneal shunt.
Nursing Management
• Implement medical regimen:
• Prepare and position patient for thoracentesis and offer support
throughout the procedure.
• Monitor chest tube drainage and water-seal system; record
amount of drainage at prescribed intervals.
• Administer nursing care related to the underlying cause of the
pleural effusion.
• Assist patient in pain relief.
• Assist patient to assume positions that are least painful.
• Administer pain medication as prescribed
• Needed to continue frequent turning and ambulation.
• If the patient is to be managed as an outpatient with a
pleural catheter for drainage, educate the patient and
family about management and care of the catheter and
drainage system.
 Emphysema
• Is a abnormal and permanent dilation of the terminal air spaces of
the lungs, combined with destruction of alveolar wall
 Emphysema
Cause
• Smoking
• Inhaled pollutants
• History of frequent respiratory infection
 Emphysema
Signs and Symptoms
• Chronic productive cough
• Hypercarbia
• Hypoxia
• Hypoxemia
• Polycythemia
• Pinkish skin
 Emphysema
• Purse lip breathing • Spirometer
• DOB
• Sleep disturbances
• Chest hyperinflation
• Cyanosis
• Right sided heart
failure
Diagnosis
 Emphysema
Management
• Prevent disease
progression
• Pharmacologic
• Nicotine replacement
• Antidepressant
• Anticholinergics
• Beta-adrenergic agonist
• Inhaled corticosteroids
• Immunization
• Pulmonary rehabilitation
• Oxygen therapy
• Postural Drainage
 Asthma
• Is a chronic inflammatory disease of the airways that causes hyper
responsiveness, mucosal edema and mucous production.
• Is a clinical syndrome characterized by three phenomena:
• Recurrent episodes of airway obstruction that resolve spontaneously or in
responsive to treatment
• Airway hyper responsiveness
• Airway inflammation
 Asthma
Cause • Hormonal factors
• Exposure to smoking • Medications
• Allergens
• Lung infection
• Stress
• Cold environment
• Exercise
• Stress
Clinical Manifestation
• Cough
• Dyspnea
• Wheezing
• Chest tightness
• Widened pulse pressure
• Hyperresonance
• Rales(crackles)
• Tachypnea
• Hyperventilation
• Mental status change- LOC,
Restlessness
 Classifications of Asthma Severity
Severity Symptoms Nighttime symptom
• Mild Intermittent • Between exacerbation, • No more than twice a
asymptomatic with normal month
PEFR
• Exacerbations
Frequency:2 or less per
week
Duration: several hours to a
few days
Intensity: varies
• Mild persitent • Exacerbations • More than twice a month
Frequency: more than 2
times a week, less than 1
time per day
May affect activity
 Classifications of Asthma Severity
Severity Symptoms Night symptoms
• Moderate persistent • Daily symptoms requiring • More than once a week
use of inhaled short-acting
beta2 agonist
• Exacerbation
Frequency: 2 or more times
per week
Duration: may last for days
Affect activity

• Severe Persistent • Continual symptoms • Frequent

• Limited physical activity
• Frequent exacerbations
Diagnosis
Asthma
• Pulmonary Function test (PFT)
• Arterial blood Gas measurement(ABG)
• Methacholine challenge test
• Chest radiographs
• Serum eosinophil and IgE level
• Electrocardiogram
• Sputum studies
• During acute episodes, sputum and blood test,
• pulse oximetry,
• hypocapnia and respiratory alkalosis, pulmonary function (forced expiratory
volume [FEV] and forced vital capacity [FVC] decreased) tests are
performed.
 Asthma
Management agonists
o Anticholinergics
• Drug Therapy o Corticosteroids: metered-dose
o Bronchodilator inhaler (MDI)
o Steroids o Leukotriene modifiers
o Mast cell stabilizers inhibitors/antileukotrienes
o MethylxanthinesThere are two o Methylxanthines
classes of medications—long-
acting control and quick-relief
medications—as well as
combination products.
o Short-acting beta2-adrenergic
 Nursing Management
• The immediate nursing care of patients with asthma
depends on the severity of symptoms.
Therefore, a calm approach is an important aspect of care.
• Assess the patient’s respiratory status by monitoring the
severity of symptoms, breath sounds, peak flow, pulse
oximetry, and vital signs.
• Obtain a history of allergic reactions to medications
before administering medications.
• Identify medications the patient is currently taking.
• Administer medications as prescribed and monitor the
patient’s responses to those medications;
• Administer fluids if the patient is dehydrated.
• Assist with intubation procedure, if required.
• Promoting Home- and Community-Based Care
• Teaching Patients Self-Care
• Teach patient and family about asthma (chronic
inflammatory), purpose and action of medications,
triggers to avoidand how to do so, and proper inhalation
technique.
Instruct patient and family about peak-flow monitoring.
• Teach patient how to implement an action plan and how
and when to seek assistance.
• Obtain current educational materials for the patient based
• on the patient’s diagnosis, causative factors, educational
• level, and cultural background.
 Continuing Care

• Emphasize adherence to prescribed therapy, preventive

measures, and need for follow-up appointments.
• Refer for home health nurse as indicated.
• Home visit to assess for allergens may be indicated (with
recurrent exacerbations).
• Refer patient to community support groups.
• Remind patients and families about the importance of
health promotion strategies and recommended health
screening.