Lower Respiratory Problems

Chapter 27
Lower Respiratory Problems
Copyright © 2020 by Elsevier, Inc. All rights reserved.

Lower Respiratory Tract
Infections
Copyright © 2020 by Elsevier, Inc. All rights reserved. 2

Acute Bronchitis (1 of 2)
 Self-limiting inflammation of bronchi; most caused
by viruses
 Other triggers: pollution, chemical inhalation,
smoking, chronic sinusitis, and asthma
 Symptoms: *cough, clear/purulent sputum,
headache, fever, malaise, dyspnea, chest pain

Acute Bronchitis (2 of 2)
 Diagnosis—based on assessment
 Breath sounds: crackles or wheezes
 Treatment goal—symptom relief and prevent
pneumonia; supportive
 Cough suppressants, oral fluids, humidifier
 2-agonist inhaler—wheezing or underlying pulmonary
condition
 Avoid irritants
 Influenza—antivirals within 48 hours
 See HCP: fever, dyspnea, or duration greater than 4
weeks
Pertussis (1 of 3)
 Bordetella pertussis
 Gram-negative bacteria attach to cilia, release toxins
results in inflammation
 Highly contagious; increased incidence in United
States
 Immunity from DPT decreases over time
 CDC recommends a one-time vaccine for adolescents
(greater than 11+ years) and adults who did not have
Tdap

Pertussis (2 of 3)
 Manifestations
 Stage 1 (1 to 2 weeks): low-grade fever, runny nose,
watery eyes, general malaise, and mild,
nonproductive cough
 Stage 2 (2 to 10 weeks): paroxysms of cough
 Stage 3 (2 to 3 weeks): less severe cough, weak
 Hallmark characteristic: uncontrollable, violent,
cough with “whooping’ sound

Pertussis (3 of 3)
 Diagnosis:
 Community: H & P
 Clinical setting: nasopharyngeal cultures, PCR of
nasopharyngeal secretions, or serology testing
 Treatment: macrolides or trimethoprim-
sulfamethoxazole
 Also for close contact exposure
 Routine and droplet precautions

Pneumonia

Pneumonia
 Acute infection of lung parenchyma
 Associated with significant morbidity and
mortality rates
 Pneumonia and influenza are eighth leading
cause of death in the United States

Pneumonia: Etiology (1 of 2)
 Normal defense mechanisms:
 Air filtration, epiglottis closure over trachea, cough
reflex, mucociliary escalator, and reflex
bronchoconstriction; IgA, IgG, alveolar macrophages
 Defense mechanisms become incompetent or
overwhelmed
 Aspiration, tracheal intubation, air pollution, smoking,
viral URI, aging, chronic diseases
 See: Risk Factors for Pneumonia Table 27-1

Pneumonia: Etiology (2 of 2)
Three ways organisms reach lungs:
1. Aspiration of normal flora from nasopharynx or
oropharynx
2. Inhalation of microbes present in air
3. Hematogenous spread from primary infection
elsewhere in body

Case Study (1 of 47)
 D.T. is an 88-year-old woman who lives alone.
She has been feeling weaker over past 2 days.
Last night became confused and disoriented.
Her housekeeper notified her daughter, who
brought D.T. to the clinic. She reports coughing
over the past 3 days.

 She has a history of mild heart failure that is
treated medically but has no other significant
health disorders.
 She last saw her health care provider 4 months
ago.

1. What are D.T.’s risk factors for pneumonia?
2. What type of pneumonia is D.T. likely

exhibiting?

Classifications of Pneumonia (1 of
4)
 May be classified according to causative organism,
characteristics of disease, or radiographic
appearance
 Most effective classification:
 Community-acquired (CAP) or
 Hospital-acquired (HAP)
• Helps identify most likely organism and antimicrobial
therapy
• See: Table 27-2

4)
 Community-acquired pneumonia (CAP)
 Acute infection in patients who have not been
hospitalized or resided in a long-term care facility
within 14 days of the onset of symptoms
 Can be treated at home or hospitalized dependent on
patient’s age, VS, mental status, comorbidities, and
condition
 Assessment: Expanded CURB-65 Table 27-3

4)
 Hospital-acquired pneumonia (HAP) or nosocomial
pneumonia
 HAP: Occurs 48 hours or longer after hospitalization
and not present at time of admission
 Ventilator-associated pneumonia —VAP: Occurs
more than 48 hours after endotracheal intubation

4)
 Empiric antibiotic therapy
 Start treatment before definitive diagnosis based on:
• Risk factors
• Early versus late onset
• Presentation
• Underlying medical conditions
• Hemodynamic stability
• Most likely causative organism

Types of Pneumonia (1 of 7)
 Viral—most common
 May be mild or life-threatening
 Bacterial
 May require hospitalization
 Mycoplasma—atypical
 Aspiration
 Necrotizing
 Opportunistic

 Aspiration pneumonia
 Abnormal entry of oral or gastric material into lower
airway
 Major risk factors:
• Decreased level of consciousness
 Depressed cough or gag reflex
• Difficulty swallowing
• Insertion of nasogastric tubes with or without tube
feeding

 Aspiration pneumonia
 Aspirated material triggers inflammatory response
 Primary bacterial infection most common
 Empiric therapy based on probable causative
organism, severity of illness, and patient factors
 Aspiration of acid gastric contents initially causes
chemical (noninfectious) pneumonitis results in
possible bacterial infection in 24 to 72 hours

 Necrotizing pneumonia
 Rare complication of bacterial lung infection; often
results from CAP
 Signs and symptoms:
• Immediate respiratory insufficiency/failure
• Leukopenia
• Bleeding into airways
 Treatment—long-term antibiotics; possible surgery

 Opportunistic pneumonia
 Immunocompromised patients
• Severe protein-calorie malnutrition
• Immunodeficiencies
• Chemotherapy/radiation recipients
• Immunosuppression therapy; long-term corticosteroid
therapy
 Caused by bacteria, virus, or microorganisms that do
not normally cause disease

 Pneumocystis jiroveci pneumonia (PJP)—fungal
infection; most common with HIV
 Slow onset and subtle symptoms:
• Fever, tachycardia, tachypnea, dyspnea, nonproductive
cough, and hypoxemia
• Chest x-ray: diffuse bilateral infiltrates to massive
consolidation
 Can be life-threatening: respiratory failure
 Spread to other organs
 Treatment: trimethoprim/sulfamethoxazole
• Does not respond to antifungals

 Cytomegalovirus (CMV) pneumonia
 Herpes virus
 Asymptomatic and mild to severe disease (impaired
immunity)
 Most important life-threatening complications after
hematopoietic stem cell transplantation
 Treatment: antiviral medications and high-dose
immunoglobulin

Pathophysiology of Pneumonia
(Fig. 27-1)

1. What manifestations of pneumonia is D.T.
displaying?
2. For what other manifestations would you
assess D.T. ?
3. What diagnostic tests would you expect the
nurse practitioner in the clinic to order?

Manifestations (1 of 2)
 Most common:
 Cough: productive or nonproductive
 Green, yellow, or rust-colored sputum
 Fever, chills
 Dyspnea, tachypnea
 Pleuritic chest pain
 Older or debilitated patients: confusion or stupor;
hypothermia

 Physical examination
 Fine or coarse crackles
 With consolidation:
• Bronchial breath sounds
• Egophony
• Increased fremitus
 With pleural effusion
• Dullness to percussion

Complications of Pneumonia (1 of
2)
 Multidrug-resistant (MDR) pathogens—major
problem in treatment
 Risk factors:
 Advanced age
 Immunosuppression
 History of antibiotic use
 Prolonged mechanical ventilation

Complications of Pneumonia (2 of
2)
 Atelectasis
 Pleurisy
 Pleural effusion
 Bacteremia
 Pneumothorax
 Acute respiratory failure
 Sepsis/septic shock
 Lung abscess
 Empyema

Diagnostic Studies (Table 27-4)
 History and physical examination
 Chest x-ray (Fig. 27-3)
 Thoracentesis and/or bronchoscopy
 Pulse oximetry
 Arterial blood gases (ABGs)
 Sputum gram stain, culture & sensitivity
 Ideally before antibiotics started
 Blood cultures
 CBC with differential

 D.T.’s chest x-ray shows consolidation in her left
lower lobe, consistent with pneumonia.
 WBC is 17,000/μL (17 × 109/L) with an
increased number of bands.
 Electrolytes are within normal limits.
 Sputum Gram stain shows gram-positive
diplococci and many WBCs.

 Because of her age and altered mentation, the
health care provider admits her to the hospital
for treatment.
 On admission, D.T. has bronchial breath sounds
with dullness of the left lower lobe and
egophony.

 Her O2 saturation is 87%.
 What is your priority of care for D.T.?

Interprofessional Care (1 of 2)
 Pneumococcal vaccines (Table 27-5)
 Prevent Streptococcus pneumoniae
 Examples: Prevnar 13 and Pneumovax 23
 *Prompt treatment with antibiotics
 Response generally occurs within 48 to 72 hours
• Decreased temperature
• Improved breathing
• Decreased Chest discomfort
 Repeat chest x-ray in 6 to 8 weeks

Interprofessional Care (2 of 2)
 Supportive care
 Oxygen for hypoxemia
 Analgesics for chest pain
 Antipyretics for fever
 Adjuvant drugs
 Individualize rest and activity
 Viral pneumonia—no definitive treatment
 Antivirals: influenza and herpes

CAP: Drug Therapy (Table 27-6)
 Initial empiric therapy
 Gram-negative and gram-positive organisms
 Likely infecting organism (Table 27-2) and risk factors
for MDR organisms; varies with local and institutional
prevalence and resistance patterns
 Should see improvement in 3 to 5 days or need to
reevaluate
 Antibiotics: IV, proceed to oral when stable; at least 5
days; afebrile 48 to 72 hours

Nutritional Therapy
 Adequate hydration; monitor intake
 Prevent dehydration
 Thin and loosen secretions
 Adjust for older adults, patients with heart failure, or
those with preexisting respiratory conditions
 Small, frequent, high calorie, nutritious meals;
monitor weight

Nursing Management: Pneumonia
Nursing Assessment (Table 27-7)
 Subjective data
 Past health history: lung cancer, COPD, diabetes,
malnutrition, chronic debilitating disease
 Use of antibiotics, corticosteroids, chemotherapy, or
immunosuppressants
 Recent abdominal or thoracic surgery
 Recent intubation
 Tube feedings

(1 of 2)
 Subjective data
 Functional health patterns
• Health perception–health management
 Smoking, alcoholism, respiratory infection, malaise
• Nutritional–metabolic
 Anorexia, nausea, vomiting; chills
• Activity–exercise
 Bed rest or altered mobility, fatigue, weakness, dyspnea,
cough, nasal congestion
• Cognitive–perceptual
 Pain with breathing, chest pain, sore throat, abdominal pain,
headache, muscle aches

(2 of 2)
 Objective data
 General: fever, restlessness or lethargy, splinting
affected area
 Respiratory: tachypnea, asymmetric chest
movements, use of accessory muscles, nasal flaring,
decreased excursion, crackles, friction rub, dullness
on percussion, increased tactile fremitus, sputum
amount and color

Nursing Assessment
 Cardiovascular: tachycardia
 Neurologic: changes in mental status
 Possible diagnostic findings:
 Increased WBCs
 Abnormal ABGs
 Positive sputum
 Abnormal chest x-ray

Nursing Diagnoses
 Impaired gas exchange
 Impaired breathing
 Fluid imbalance
 Hyperthermia
 Activity intolerance

Planning
Goals:
 Clear breath sounds
 Normal breathing patterns
 No signs of hypoxia
 Normal chest x-ray
 Normal WBC count
 Absence of complications

Nursing Implementation
 Health promotion
 Teach hygiene, nutrition, rest, regular exercise
 Cough or sneeze into elbow
 *Avoid cigarette smoke
 Avoid exposure to URIs; prompt treatment
 Identify risk factors (Table 27-1)
 Influenza and pneumococcal vaccines (Table 27-5)

Nursing Implementation: Acute
Care (1 of 3)
 Monitor assessment parameters, provide treatment,
and monitor response
 Collaborate with respiratory therapy, PT
 Collect specimens
 Administer antibiotics
 Oxygen, hydration, nutrition, breathing exercises,
early ambulation, and positioning

Care (2 of 3)
 Prevent aspiration pneumonia
 Elevate head-of-bed 30 degrees and have sit up for
all meals
 Assist with eating, drinking, taking meds as needed
 Assess for gag reflex
 Monitor reflux and gastric residuals (NG tube)
 Early mobilization
 Cough and deep breathe, incentive spirometry
 Twice-daily oral hygiene

Care (3 of 3)
 Medical asepsis and infection control
 Hand hygiene
 Sterile technique with tracheal suction
 Careful handling of respiratory equipment
 Avoid inappropriate antibiotic use

 It has been 4 days since D.T. was admitted for
pneumonia.
 She is hemodynamically stable and

neurologically intact.

 She has been switched from IV antibiotics to oral
antibiotics and is ready for discharge.
 What important teaching should you provide to

the patient and family?

Nursing Implementation:
Ambulatory Care
 Patient teaching for home care
 Emphasize need to take full course of antibiotics
 Drug-drug and drug-food interactions
 Adequate rest
 Adequate hydration
 Avoid alcohol and smoking
 Cool mist humidifier or warm bath
 Chest x-ray, vaccinations
 Takes several weeks (or more) to recover

Evaluation
 Expected outcomes:
 Effective respiratory rate, rhythm, and depth of
respirations
 Lungs clear to auscultation
 Absence of infection

Audience Response Question (1 of
2)
A 56 year old normally healthy patient at the clinic
is diagnosed with bacterial community-acquired
pneumonia. Before treatment is prescribed, the
nurse asks the patient about an allergy to:
a. amoxicillin.
b. erythromycin.
c. sulfonamides.
d. cephalosporins .

2)
Answer: B
erythromycin

2)
The nurse is caring for a patient with pneumonia. If
a pleural effusion is developing, the nurse would
expect which finding?
a. Barrel-shaped chest
b. Paradoxical respirations
c. Hyperresonance on percussion
d. Localized decreased breath sounds

2)
Answer: D
Localized decreased breath sounds

Tuberculosis

Tuberculosis (TB)
 Infectious disease caused by Mycobacterium
tuberculosis
 Lungs most commonly infected
 1/3 of world’s population has TB
 Prevalence in the United States decreasing

 S.C. is a 57-year-old Chinese man who was
transported from a homeless shelter for having
respiratory symptoms.
 He has a history of IV drug use and is HIV
positive.
 He has been coughing regularly and producing
mucopurulent sputum.

1. What risk factors does S.C. have for TB?
2. What diagnostic tests would you expect the

HCP to order for S.C.?

Risk Factors for TB
 Poor, underserved, and minorities
 Homeless
 Residents of inner-city neighborhoods
 Foreign-born persons
 Living or working in institutions
 IV injecting drug users
 Overcrowded living conditions
 Poverty, poor access to health care

Multidrug-Resistant Tuberculosis
(MDR-TB)
 Resistance to 2 of the most potent first-line anti-TB
drugs (isoniazid and rifampin)
 Extensively drug-resistant TB (XDR-TB) resistant to
any fluoroquinolone plus any injectable antibiotic
 Several causes for resistance:
 Incorrect prescribing
 Lack of public health case management
 Nonadherence
 Lack of funding for education and prevention

Etiology and Pathophysiology
(1 of 3)
 Gram-positive, aerobic, acid-fast bacillus (AFB)
 Spread via airborne droplets, 1 to 5 m
 Can be suspended in air for minutes to hours
 Transmission requires close, frequent, or prolonged
exposure
 NOT spread by touching, sharing food utensils,
kissing, or other physical contact
 Number, concentration, length of time for exposure
and immunity influence transmission

(2 of 3)
 Once inhaled, droplets lodge in bronchioles and
alveoli
 Local inflammatory reaction occurs
 Ghon lesion or focus—represents a calcified TB
granuloma—primary TB infection
 Granuloma—defense mechanism to wall off and
prevent spread
 Only 5% to 10% of people with dormant TB will
develop active TB; may take months or years

(3 of 3)
 M. tuberculosis
 Aerophilic (oxygen-loving)—has affinity for lungs
 Infection can spread via lymphatics and grow in other
organs
• Cerebral cortex, spine, epiphyses of the bone, adrenal
glands, liver, kidneys, and lymph nodes

Classification of TB
(American Thoracic Society)
 Class (Table 27-8)
 0 = No TB exposure
 1 = Exposure, no infection
 2 = Latent TB, no disease
 3 = TB, clinically active
 4 = TB, not clinically active
 5 = TB suspect

Another Classification System
 Presentation
 Primary TB infection
 Bacteria are inhaled, inflammatory response occurs; if
adequate immune response infection does not
progress to disease
 Active TB disease
 Primary TB—active disease within 2 years of infection
 Reactivation TB (post-primary)—disease occurs
greater than 2 years after infection; infectious

Classification
 Latent TB infection (LTBI) (Table 27-9)
 Infected (positive skin test) but not active disease
 Asymptomatic
 Noninfectious—can’t transmit
 May develop active TB later
• Immunosuppression, diabetes, aging, pregnancy,
stress, chronic disease
 Important to treat to prevent active TB

 Pulmonary TB
 Takes 2 to 3 weeks to develop symptoms
 Characteristic initial: dry cough that becomes
productive
 Other symptoms: fatigue, malaise, anorexia, weight
loss, low-grade fever, night sweats
 Late: dyspnea and hemoptysis

 Acute, sudden presentation of TB
 High fever
 Chills, generalized flulike symptoms
 Pleuritic pain
 Productive cough
 Crackles and/or adventitious breath sounds

 Immunosuppressed (e.g., HIV) and older adults—
less likely to have fever and other signs of an
infection
 HIV—carefully investigate respiratory problems; rule
out PJP or opportunistic diseases
 Older adult—change in cognitive function may be the
only initial sign
 Extrapulmonary TB manifestations—depends on
organs infected

Complications (1 of 3)
 Miliary TB
 Large numbers of organisms spread via the
bloodstream to distant organs
 Occurs with primary TB or reactivation of LTBI
 Fatal if untreated
 Manifestations progress slowly and vary depending
on which organs are infected
• Fever, cough, and lymphadenopathy
• May include hepatomegaly and splenomegaly

 Pleural TB—extrapulmonary
 Primary TB disease or reactivation of LTBI
 Pleural effusion
 Empyema

 Acute
and long-term complications may occur
when TB infects other organs
• Spine (Pott’s disease)—destruction of
intervertebral discs and adjacent vertebrae
• CNS—bacterial meningitis
• Abdomen—peritonitis
• Other: kidneys, adrenal glands, lymph nodes and
urogenital tract

Diagnostic Studies (1 of 6)
 Tuberculin skin test (TST)
 AKA: Mantoux test
 Screening for TB: Purified protein derivative (PPD)—
0.1 mL ID injection ventral forearm
• Inspect site for induration in 48 to 72 hours
• Induration—palpable, raised, hardened, or swollen
area (not redness)
 Indicates development of antibodies following exposure
to TB
 Measure in mm and record

 TST
 See Table 25-14—Interpretation guidelines
 Positive
• Greater than or equal to 15 mm induration in low-risk
individuals
• Greater than 10 mm induration in high-risk
• Greater than or equal to 5 mm induration in
immunocompromised
 False-positive and false-negative reactions may also
occur

 TST
 Initial screening: 2-step testing
• Antibody formation takes 2 to 12 weeks
 Recommended for health care workers and those with
decreased response to allergens
 Initial injection; second injection in 1 to 3 weeks
• Initial positive—need further evaluation
• Second positive—new infection or boosted reaction to
old infection
 Negative 2-step testing ensures future positive results
accurately interpreted as new infection

 Interferon-γ (INF-gamma) release assays (IGRAs)—
screening tool
 Blood test detects INF gamma release from T-cells in
response to M. tuberculosis
• Includes QuantiFERON ®-TB Gold In-Tube (QFT-GIT)
and T-SPOT.TB® tests
• Rapid results
• Several advantages over TST but  cost

 Chest x-ray
 Cannot make diagnosis solely on x-ray
 May appear normal in a patient with TB
 Suggestive findings:
• Upper lobe infiltrates
• Cavitary infiltrates
• Lymph node involvement
• Pleural and/or pericardial effusion

 Bacteriologic Studies
 *TB culture is gold standard
• Three consecutive sputum samples at 8 to 24 hours
intervals; at least specimen in early morning
• Initial test: stained sputum smears examined for AFB
• Definitive diagnosis = mycobacterial growth—can take
up to 6 weeks
• Can also collect samples from other suspected TB sites

 S.C.’s chest x-ray and sputum smear for AFB
confirm the TB diagnosis.
 What treatment would you expect the health
care provider to order for S.C.?
 Do you think S.C. needs to stay in the hospital
at this point?

Interprofessional Care (Table 27-
10)
 Most patients treated as outpatients
 Infectious for first 2 weeks after starting treatment if
sputum +
 Restrict visitors and limit public exposure
 Hand hygiene and oral hygiene
 Aggressive drug therapy used to treat active
disease and prevent MDR-TB; monitor adherence
 See Tables 27-11 and 27-12

Drug Therapy (1 of 6)
 Two phases of treatment:
• Initial (8 weeks to 3 months): 4 drugs (below)
• Continuation (18 weeks): 2 drugs (isoniazid and
rifampin)
 Initial 4-drug regimen:
• Isoniazid (hepatitis)
• Rifampin (hepatitis; orange body fluids)
• Pyrazinamide (hepatitis)
• Ethambutol (ocular toxicity)

 Patients should be taught about adverse/side effects
and when to seek medical attention
 Nonviral hepatitis is a major side effect for 3 of 4 first-
line drugs; liver function tests should be monitored
 Alternatives are available for those who develop a
toxic reaction to primary drugs

 MDR-TB
 Sensitivity test determines drugs
 Initial: Five drugs for at least 6 months
• 2 first-line, fluoroquinolone, injectable antibiotic and 1
or more second-line
 Continuation: 4 drugs for 18 to 24 months
 Two new drugs used in combination therapy
• Bedaquiline (Sirturo)
• Delamanid (Deltyba)

 Directly observed therapy (DOT)
 Nonadherence is major factor in MDR-TB and
treatment failures
 Provide drugs and watch patient swallow
 Expensive but preferred public health strategy to
ensure adherence
 May be given by public health nurses at clinic site

 Latent tuberculosis infection (LTBI)
 Usually treated with Isoniazid for 6 to
9 months (See Table 27-13)
 HIV patients and those with fibrotic lesions on chest x-
ray should take Isoniazid for 9 months
 Alternative 3-month regimen of Isoniazid and
rifapentine OR 4 months of rifampin

 Bacille-Calmette-Guerin (BCG) Vaccine
 Live, attenuated strain of Mycobacterium bovis
 Given to infants in parts of world with high prevalence
of TB
 In United States, not recommended due to low risk of
infection except for select individuals
 BCG vaccine can result in false positive TST

Nursing Management:
Nursing Assessment
 History
 TB, chronic illness, immunosuppression
 Social and occupational risk factors
 Physical symptoms
 Productive cough (collect sputum for AFB in early
morning), night sweats, fever, weight loss, pleuritic
chest pain, abnormal breath sounds

Nursing Diagnoses
 Impaired airway clearance
 Risk for infection
 Lack of knowledge

Planning
 Goals:
 Have normal pulmonary function
 Adhere with therapeutic regimen
 Take appropriate measures to prevent spread of
disease
 Have no recurrence of disease

Nursing Implementation (1 of 5)
 Ultimate goal worldwide: eradication
 Selective screening programs detect TB in high-risk
groups
 Treatment of LTBI to decreased carriers
 Positive TST results: chest x-ray
 TB—reportable to public health authorities to identify
contacts and risk to community
 Address social determinants of TB
 Improve access to health care and education

1. What is the primary nursing management for
S.C.?
2. What hygiene measures can you teach him to

minimize transmission?

 Acute care
 Airborne isolation
• Single-occupancy room with 6 to 12 airflow
exchanges/hour
• Health care workers wear high-efficiency particulate air
(HEPA) masks; fit tested
 Immediate medical workup: chest x-ray, sputum
smear and culture
 Appropriate drug therapy

 Teach patient to prevent spread
 Cover nose and mouth with tissue when coughing,
sneezing, or producing sputum; dispose in trash or
flush
 Hand washing after handling sputum-soiled tissues
 Patient wears face mask if outside of negative-
pressure room
 Identify and screen close contacts

 S.C. is now ready for discharge.
 What other patient teaching should you do with

him?
 What can you do to help ensure that he

continues medications after discharge?

 Ambulatory care
 May go home even if cultures positive
 Monthly sputum cultures
• Two consecutive negative cultures = noninfectious
 Teach patient how to minimize exposure to others
 Teach importance of adherence to patient and
caregiver; provide strategies

 Ambulatory care
 Notify public health department
• Public health nurse follow-up
• DOT
 Teach symptoms of recurrence, factors that could
reactivate TB
 Smoking cessation

Evaluation
 Expected outcomes
 Resolution of disease
 Normal pulmonary function
 Absence of any complications
 No further transmission of TB

Atypical Mycobacteria
 30+ varieties of acid-fast mycobacteria that
cause pulmonary disease, lymphadenitis, skin or
soft tissue disease, or disseminated disease
 Found in tap water, soil, house dust, or bird
feces
 Symptoms: cough, shortness of breath, weight
loss, fatigue, blood-tinged sputum
 Diagnosis: culture
 Treatment: similar to TB

Pulmonary Fungal Infections
 Caused by endemic or opportunistic fungi (Table
27-14)
 May be life threatening
 Transmission: inhalation of spores
 Symptoms: similar to bacterial pneumonia
 Diagnosis: skin testing, serology, biopsy
 Treatment: antifungals

Lung Abscess (1 of 4)
 Etiology and pathophysiology
 Necrosis of lung tissue from aspiration of bacteria from
periodontal disease
• Other: IV drug use, cancer, PE, lung infarction, TB, parasitic
and fungal diseases, sarcoidosis
 Develops slowly; infection results in purulent fluid filled
cavity with multiple microbes
 Posterior upper lobes most often affected
• May erode into bronchi: foul-smelling sputum
• May grow into pleura: pleuritic pain
 Multiple abscesses—necrotizing pneumonia

 Manifestations:
 Cough-producing purulent sputum; foul smell and
taste; hemoptysis
 Other: fever, chills, night sweats, pleuritic pain,
dyspnea, anorexia, weight loss
 Decreased breath sounds; crackles
 Complications: pulmonary abscess, bronchopleural
fistula, bronchiectasis, empyema

 Diagnostic studies
 Chest x-ray
 Other: CT scan; sputum, pleural fluid, and blood
cultures; bronchoscopy, WBC
 Nursing and interprofessional management
 Monitor for signs of hypoxemia, respiratory distress;
apply O2
 IV antibiotics initially then switch to oral therapy
• Patient education—complete entire prescription

 Nursing and interprofessional management
 Teach: effective coughing
 Supportive measures: rest, nutrition, fluids
 Dental care
 If antibiotics not effective—
• Percutaneous drainage of abscess
• Surgery: lobectomy or pneumonectomy

Environmental Lung Diseases (1 of
5)
 Environmental or occupational inhalation of dust or
chemicals
 Lung damage depends on:
• Toxicity
• Amount and duration of exposure
• Susceptibility of individual

5)
 Pneumoconiosis—inhaled mineral or metal dust
particles
 Classified by origin:
• Silicosis—sand or rock
• Coal worker’s pneumoconiosis—“black lung” results in
pulmonary fibrosis
• Asbestosis results in mesothelioma; cancer occurs 15
to 19 years from exposure

5)
 Chemical pneumonitis
 Inhalation of toxic chemical fumes
• Acute—diffuse lung injury
• Chronic—bronchiolitis obliterans
 Hypersensitivity pneumonitis
 Extrinsic allergic alveolitis—inhaled allergic antigens
• Bird fancier’s lung (feathers and bird droppings
• Farmer’s lung (hay dust)
• Acute, subacute, chronic forms

5)
 Manifestations (10 to 15 years)
 Dyspnea, cough, wheezing, weight loss
 Pulmonary function tests: reduced vital capacity
 Chest x-ray, CT scans—lung involvement
 Cor pulmonale—right heart failure due to diffuse
fibrosis
 Complication: *COPD
 Other: acute pulmonary edema, lung cancer,
mesothelioma, TB

5)
 Interprofessional care
 Prevention
• Personal protective equipment: masks, ventilation
systems, no smoking
• Follow OSHA and NIOSH regulations
 Check-ups/early diagnosis
• O2, IV fluid, bronchodilators, NSAIDs corticosteroids,
intubation/mechanical ventilation, percussion,
pulmonary rehab
• Influenza and pneumonia vaccines

Lung Cancer

Lung Cancer
 Leading cause of cancer-related deaths (28%) in
United States
 Estimated 234,000 new cases in 2018; 154,000
deaths
 High mortality rate; low cure rate
 Advances in treatment improving response

 J. B. is a 62-year-old man who was diagnosed
with lung cancer 2 weeks ago.
 He has smoked 2 packs of cigarettes per day for
past 40 years.
 He works as chemical engineer in the plastics
industry.

1. What factors in J.B.’s history increase his risk
for lung cancer?
2. What other factors might you question J.B.

about?

Etiology (1 of 4)
 Smoking—most important risk factor in 80% to 90%
of all lung cancers; no safe form of tobacco
 Contains 7000 chemicals; 250 harmful
 69 carcinogens that interfere with cell development
 Causes a change in bronchial epithelium
 Smoking cessation reduces risk

Etiology (2 of 4)
 Risk related to total exposure to tobacco smoke
 Total number of cigarettes smoked
 Age of smoking onset
 Depth of inhalation
 Tar and nicotine content
 Use of unfiltered cigarettes
 Sidestream (secondhand) smoke is also a health
risk

Etiology (3 of 4)
 Other causes of lung cancer include exposure to:
 Pollution
 Radiation /radon
 Asbestos
 Industrial agents (nickel, uranium, chromium,
formaldehyde, arsenic)

Etiology (4 of 4)
 Significant variation in likelihood of developing
cancer
 Gender
 Genes
 Hormones
 Molecular influences

Pathophysiology (1 of 2)
 Arise from mutated epithelial cells
 Tumor development promoted by epidermal growth
factor
 It takes 8 to 10 years for a tumor to reach 1 cm
 Smallest lesion detectable on x-ray
 Occur primarily in segmental bronchi and upper
lobes

Pathophysiology (2 of 2)
 Primary lung cancers categorized into 2 subtypes
 Non–small-cell lung cancer (NSCLC); 85%
 Small-cell lung cancer (SCLC); 15%
 Metastasis—direct extension and blood and lymph
system
 Common sites: lymph nodes, liver, brain, bones, and
adrenal glands

Non–Small-Cell Lung Cancer
(NSCLC)
 Squamous cell carcinoma
 Slow growing
 Early symptoms: cough and hemoptysis
 Adenocarcinoma
 Moderate growing
 Most common in nonsmokers
 Large-cell carcinoma
 Rapid growing
 Highly metastatic

Small-Cell Lung Cancer (SCLC)
 Very rapid growth
 Most malignant
 Early metastasis
 Associated endocrine disorders
 Chemotherapy and radiation
 Poor prognosis

Pathophysiology
 Paraneoplastic syndrome
 Caused by hormones, cytokines, enzymes, or
antibodies that destroy healthy cells
 May manifest before cancer diagnosed
 Associated most with SCLC
 Examples: hypercalcemia, SIADH, adrenal
hypersecretion, polycythemia, Cushing’s syndrome

 J.B. comes to the emergency room because he
feels like he “just can’t breathe right.”
 On arrival he tells you that he has small-cell lung
carcinoma.
 How does the prognosis for this type of lung
cancer compare to other types of lung cancer?

 Where would J.B.’s cancer most likely
metastasize to?

 What manifestations of lung cancer would you
assess J.B. for?

 Symptoms nonspecific and appear late in
disease
 May be masked by chronic cough
 Depend on type of primary lung cancer, location,
and metastatic spread

 Persistent cough with sputum (most common)
 Hemoptysis
 Dyspnea
 Wheezing
 Chest pain

 Later manifestations
 Anorexia, nausea/vomiting, fatigue, weight loss
 Hoarseness
 Unilateral paralysis of diaphragm
 Dysphagia
 Superior vena cava obstruction
 Palpable lymph nodes
 Mediastinal/cardiac involvement

 What diagnostic tests might J.B. have
undergone related to his lung cancer?

 Chest x-ray
 CT scan
 Sputum cytology (rarely used)
 Lung biopsy—definitive diagnosis
 Pleural fluid analysis
 Metastasis
 Bone and CT scans—brain, abdomen, and pelvis

 H&P
 CBC with differential
 Chemistry panel
 Liver, renal, and pulmonary function tests
 MRI
 PET scan

 Staging
 NSCLC staged according to TNM system
• T denotes tumor size, location, and degree of invasion
• N indicates regional lymph node invasion
• M represents presence/absence of distant metastases

Staging
 Staging of NSCLC Staging I to IV with subtypes
 Stages I, II, IIIA—potential surgery
 Stage IB or IV—inoperable
 Staging of SCLC
 Limited—one side of chest and regional lymph nodes
 Extensive—beyond limited

Screening for Lung Cancer
 Annually in adults ages 55 to 77 with a history of
smoking
 30 pack-year history
 Current smoker
 Quit less than15 years ago
 Completed with low dose CT

 J.B. has not yet agreed to any treatment for his
lung cancer.
 What type of treatments would you expect to be

offered to J.B.?

Interprofessional Care
Surgical Therapy
 Treatment of choice for NSCLC Stages I to IIIA;
best chance for a cure
 Survival is related to size of the primary tumor
and co-morbidities; assess cardiopulmonary
 Procedures:
• Segmental or wedge resection
• Lobectomy
• Pneumonectomy
• VATS

Radiation Therapy
 NSCLC and SCLC
 Used as curative therapy, palliative therapy, or
adjuvant therapy
 Primary therapy for those unable to tolerate
surgery
 Relief of symptoms: dyspnea, hemoptysis, SVC
syndrome, and pain
 Preoperative to reduce tumor mass
 Monitor for complications

Stereotactic Body Radiotherapy
(SBRT)
 Stereotactic radiosurgery (SRS)
 High dose of radiation accurately delivered to
tumor (outside CNS)
 Smaller part of healthy lung exposed
 Damages tumor DNA
 Therapy is given over 1 to 3 days
 Option for nonsurgical, early stage lung cancer

Chemotherapy
 Primary treatment for SCLC
 Treatment of nonresectable tumors or adjuvant
to surgery in NSCLC
 Variety of drugs and protocols
 Typically combination of two or more drugs

Targeted Therapy
 Block tumor growth; less toxic than
chemotherapy
 Tyrosine kinase inhibitors—block signals for
growth in cancer cells
 Kinase inhibitor—inhibits kinase protein
responsible for cancer development and growth
 Angiogenesis inhibitor—inhibits growth of new
blood vessels

Immunotherapy
 Targets PD-1, a protein on T cells that normally helps
keep these cells from attacking other cells in the body
 Boosts immune response against cancer cells
 Shrink tumor cells or slow growth
 Can be used in people with squamous cell NSCLC
whose cancer progressed after other treatments

Other Therapies (1 of 2)
 Prophylactic cranial irradiation
 Prevent brain metastasis with limited SCLC
 Bronchoscopic laser therapy
 Remove obstructing tumors from bronchi
 Photodynamic therapy (PDT)
 Photosynthesizer and laser used to kill tumor cells

Other Therapies (2 of 2)
 Airway stenting
 Supports airway wall or prevent external
compression; relieves dyspnea, cough, or respiratory
insufficiency
 Radiofrequency ablation
 Alternative to surgery for small NSCLC lung tumors
near outer edge of lungs
 Electric current, delivered through a probe, heats and
destroys tumor cells

 J.B. is admitted to clinical unit for stabilization of
his respiratory status.

 Prior to transfer the nurse provides a
comprehensive report to the receiving RN.
 What data would the nurse include related to
the “B” portion of an SBAR hand-off ?

 What assessment data would you obtain when
admitting J.B. to the hospital?

Nursing Management
Nursing Assessment
 Assess patient’s and family’s understanding of
current medical condition, diagnostic tests,
diagnosis, treatment options, and prognosis
 Patient’s level of anxiety
 Support systems

Nursing Assessment (1 of 5)
Subjective data
 Past health history
 Exposure to smoke, carcinogens, or pollution;
chronic lung diseases
 Medications
 Useof cough medicines or other respiratory
medications

 Functional health patterns
 Health perception–health management
• Smoking history, family history of lung cancer, frequent
respiratory infections
• Nutritional–metabolic
• Anorexia, nausea, vomiting, dysphagia, weight loss,
chills

 Activity–exercise
• Fatigue, cough, dyspnea, hemoptysis
 Cognitive–perceptual
• Pain (chest, shoulder, arm, bone); headache

Objective Data
 General
 Fever, lymphadenopathy, paraneoplastic syndrome

 Integumentary
 Jaundice, edema, clubbing
 Respiratory
 Adventitious lung sounds, pleural effusions

Objective Data
 Cardiovascular
 Pericardial effusion, dysrhythmias

 Neurologic
 Confusion, disorientation, unsteady gait
 Pathologic fractures
 Musculoskeletal
 Pathologic fractures, muscle wasting
 Diagnostic test results

 While planning care for J.B., what nursing
diagnoses would be most appropriate?

Nursing Diagnoses
 Impaired airway clearance
 Impaired gas exchange
 Anxiety

Planning
 Goals
 Adequate airway clearance
 Effective breathing patterns
 Adequate oxygenation of tissues
 Minimal to no discomfort
 Realistic outlook about treatment and prognosis

 Avoid smoking; prevent teen smoking
 Promote smoking cessation programs
 Model healthy behavior
 Support education and smoking policies
 Smoke-free environments
 Hospitals - refuse employment if positive for nicotine

 What nursing interventions would you plan for J.
B.?

 Acute care
 Offer support during diagnostic evaluation
 Monitor for stressors
• Symptoms
• Interventions
• Pain
• Emotional
• Role performance

 Acute care
 Also see chest surgery and Chapter 15:
chemotherapy and radiation therapy
 Symptom management
 Patient teaching:
• Pain relief
• Monitor for side effects
• Foster coping strategies
• Smoking cessation
• Access resources

 J.B.’s health care provider reviews his
diagnostic test findings and recommends
chemotherapy as well as radiation therapy.
 What can you do to help J.B. with anticipatory

guidance if he elects to get treatment?

 What can you do to prepare J.B. for his
discharge to home?

 Ambulatory care
 Smoking prevention/cessation
 Smoke-free environment
 Use of oxygen
 Constant pain may be a problem
 Palliative treatments
 End-of-life care

Evaluation
 Expected outcomes
 Adequate breathing patterns
 Adequate oxygenation
 Minimal to no pain
 Convey feelings openly and honestly with a realistic
attitude about prognosis

Chest Trauma and Thoracic
Injuries

Chest Trauma (1 of 2)
 Traumatic injuries to chest contribute to many
traumatic deaths
 Range of injuries
 Simple rib fractures to cardiorespiratory arrest

Chest Trauma (2 of 2)
 Mechanisms of Injury
 Blunt
• Shearing and compression injuries of chest structures
• External appearance may be minor but may have
severe internal organ damage
 Penetrating
• Foreign object impales or passes through body tissues
creating an open wound

Chest Trauma: Emergency
Management (1 of 5)
 Assess for signs of respiratory distress
 Dyspnea
 Cough with or without hemoptysis
 Cyanosis
 Tracheal deviation
 Decreased breath sounds
 Decreased O2 saturation
 Frothy secretions

Management (2 of 5)
 Assess for signs of cardiovascular compromise
 Rapid, thready pulse
 Decreased BP with narrowed pulse pressure and/or
asymmetric readings
 Distended neck veins
 Muffled heart sounds
 Chest pain
 Dysrhythmias

Management (3 of 5)
 Initial interventions
 Circulation, airway, breathing
 Apply O2 to keep SpO2 >90%
 Establish IV access with 2 large-bore catheters and
begin fluid resuscitation as appropriate
 Remove clothing to assess injury
 Cover sucking chest wound with nonporous dressing
taped on three sides

Management (4 of 5)
 Initial interventions
 Stabilize impaled objects
 Assess for other significant injuries and treat
appropriately
 Place patient in a semi-Fowler’s position or on injured
side
• After ruling out cervical spine injury
 Administer analgesia
 Prepare for emergency needle decompression

Management (5 of 5)
 Ongoing monitoring
 Vital signs
 Level of consciousness
 Oxygen saturation
 Cardiac rhythm
 Respiratory status
 Urinary output
 Potential intubation

 M. Z. is a 28-year-old male who arrives to the
ED following a high-speed motor vehicle
accident.
 He reports severe chest pain, rating it at a 10 on
a scale of 0 to 10.

 You notice that his breathing is labored.
 Part of his chest wall is moving in the opposite
direction of the remainder when he breathes.

 M.Z.’s BP is 96/50, heart rate 126, respiratory
rate 36, temp 37° C, and pulse oximetry 88% on
4L of oxygen.
 He is alert and oriented and states that his car
was “T-boned” on the driver’s side where he was
sitting.
 He has no open wounds.

Fractured Ribs (1 of 2)
 Blunt trauma
 Most common ribs 5 through 9
 Can damage pleura, lungs, heart, and other internal
organs
 Manifestations
 Pain with inspiration and coughing
 Splinting
 Shallow respirations

Fractured Ribs (2 of 2)
 Complications
 Atelectasis and pneumonia
 Treatment
 Reduce Pain: NSAIDs, opioids, nerve blocks
 Patient teaching
• Deep breathing and coughing
• Incentive spirometry
• Appropriate use of analgesics

Flail Chest (1 of 4)
 Three or more consecutive fractured ribs in 2 or
more places or fractured sternum and several
consecutive ribs
 Causes unstable chest wall and paradoxical
movement with breathing
 Flail segment moves opposite
 Inspiration—sucked in
 Expiration—bulges out
 Inadequate ventilation;  work of breathing


 Physical examination
 Rapid, shallow respirations
 Asymmetric and uncoordinated chest movement
 Inadequate ventilation
 Splinting
 Crepitus near fractures
 Diagnostic study
 Chest x-ray

 Treatment
 Ensure adequate ventilation/lung expansion
 Adequate oxygenation
 Pain management
 Other, if needed:
• Intubation and mechanical ventilation
• Surgical fixation

 How would you classify M.Z.’s trauma?
 Based on his presentation and the mechanism
of injury, what type of injury would you suspect
M.Z. to have?

Pneumothorax (1 of 5)
 Caused by air entering pleural cavity
 Positive pressure in pleural space causes lung to
partially or fully collapse
 Increased air in pleural space equals reduced lung
volume
 Open: opening in chest wall
• Penetrating trauma—sucking chest wound
 Closed: no external wound
 Suspect pneumothorax with chest wall trauma


 Manifestations
 Small pneumothorax
• Mild tachycardia and dyspnea
 Large pneumothorax
• Respiratory distress
• Absent breath sounds over affected area
 Diagnostic Study: Chest x-ray

 Types
 Spontaneous—rupture of blebs
• Can occur in healthy or chronically ill persons (COPD,
asthma, cystic fibrosis, pneumonia)
• Risk factors: Tall, thin, male, family history, or previous
spontaneous pneumothorax
 Iatrogenic —medical procedures
• Biopsies, subclavian catheter insertion, ventilator,
esophageal trauma

 What potential life-threatening complication of a
potential pneumothorax would you need to
assess M.Z. for?
 What would you look for?

 Types
 Tension pneumothorax
• Accumulation of air in pleural space that cannot escape
results in increased intrapleural pressure
• Causes mediastinal shift and hemodynamic instability:
reduced venous return and reduced cardiac output
• Can occur with open or closed pneumothorax

Tension Pneumothorax

Pneumothorax
 Tension pneumothorax = medical emergency
 Manifestations
 Severe dyspnea, tachycardia, tracheal deviation,
decreased or absent breath sounds on affected side,
neck vein distention, cyanosis, diaphoresis
 May be fatal if pressure in pleural space not relieved

Hemothorax and Chylothorax
 Hemothorax
 Blood in pleural space
 Treat with chest tube
 Hemopneumothorax
 Chylothorax
 Lymphatic fluid in pleural space
 Treat conservatively or with Octreotide
 Refractory options: surgery or pleurodesis

 Dependent on severity, underlying cause and
hemodynamic stability
 Emergency treatment—Cover wound with dressing
secured on 3 sides
• Inspiration: pulls dressing against wound so air
cannot enter pleural space
• Expiration: dressing pushes out and air escapes
 If impaled object in place, stabilize it with a bulky dressing
but do not pull it out

 Treatments
 *Chest tubes with water-seal drainage
 Other: partial pleurectomy, stapling, or pleurodesis
 Tension pneumothorax
 Needle decompression— immediate
 Chest tube and water-seal drainage

 What would be your priority nursing
assessments of M.Z.?

 What are your priority nursing interventions for
M.Z.?

 M.Z.’s chest x-ray confirms the presence of
right-sided fractures in ribs 6 to 9 in two places
each with a free- standing segment.
 He has a moderate-sized right
hemopneumothorax.
 ED physician asks to prepare for chest tube
insertion.

 How would you set up a water- suction chest
tube drainage system?
 How would you position him for insertion of
chest tube?

Chest Tubes and Pleural Drainage
 Chest tubes
 Drain pleural space
 Reestablish negative pressure
 Allow lung to expand
 20 in long
 12° to 40 ° F
• Small: air Medium: fluid Large: blood
 Pigtail tubes (10° to 14 ° F)

Chest Tube Insertion
 May be placed in ED, OR, or at bedside
 Standard insertion site: midaxillary
 HOB elevate 30 to 60 degrees; arm raised
above head
 Antiseptic cleanse; local anesthetic
 Small incision over rib, chest tube inserted
 Sutured in place; occlusive dressing
 Connect pleural drainage system
 Chest x-ray to confirm placement

Placement of Chest Tubes

Flutter or Heimlich Valve (1 of 2)
 Removes air from pleural space
 Small to moderate-sized pneumothorax
 Rigid plastic tube with one-way rubber valve inside
 Attached to external end of chest tube
 Two nozzles
 Inlet nozzle: allows air to pass in the valve through chest
drainage tube
 Outlet nozzle—air passes to environment or colleting
device during expiration

Flutter or Heimlich Valve (2 of 2)
 During inspiration, the pressure in the chest
decreases and the valve closes.
 During expiration, intrathoracic pressure
increases and the valve opens.
 Drainage bag must be vented to atmosphere to
prevent tension pneumothorax. Cut small slit in
top of bag.
 Allows for increased patient mobility
 Patients can go home with flutter valve

Flutter or Heimlich Valve

Pleural Drainage (1 of 5)
 Collection device for fluid, air, or blood from chest
cavity
 Three basic compartments
 1st compartment or collection chamber
• Fluid stays in; air vents to 2nd compartment
 2nd compartment or water-seal chamber
• Contains 2 cm of water; acts as one-way valve; air
goes in, bubbles out, but can’t go back to patient
 3rd compartment or suction control chamber
• Uses column of water to control suction from regulator

Chest drainage unit. This unit has 3 chambers: (1) collection chamber; (2) water-seal
chamber; and (3) suction control chamber. Suction control chamber requires a
connection to a wall suction source that is dialed up higher than the prescribed suction
for the suction to work. In the water suction unit, the suction control chamber controls
the wall suction pressure. (From Atrium Medical Corporation, Hudson, N.H.)

Chest drainage unit. This unit has 3 chambers: (1) collection chamber; (2) water-seal
chamber; and (3) suction control chamber. Suction control chamber requires a
connection to a wall suction source that is dialed up higher than the prescribed suction
for the suction to work. In the dry suction unit the wall suction is controlled by using a
regulator control dial. (From Atrium Medical Corporation, Hudson, N.H.)

 Bubbling in water-seal chamber
 Brisk at first, eventually disappears as lung expands
 Intermittent with exhalation, coughing, or sneezing
 Tidaling in water-seal chamber
 Fluctuation of water with pressure changes during
respiration
 Disappears as lung re-expands
 If stops suddenly, check for occlusion

 Suction control chamber
 Wet suction
• Amount of water in chamber (20 cm) controls suction
• Excess suction from source vented
• Usual suction order = −20 cm H2O
• Adjust suction until gentle bubbling in third chamber
 Dry suction—no water (less noise)
• Dial regulator to pressure; visual alert

Nursing Management:
Chest Drainage
 Set-up and Insertion
 Consent/Aware of procedure
 Gather and set-up equipment as per order
 Drainage system
 Keep tubing loosely coiled
 Keep connections tight; taped
 Observe: tidaling, bubbling, air leak, fluid levels

 M.Z. tolerated the chest tube insertion well.
 The tube is attached to a water-seal drainage
unit and to wall suction with −20 cm of water in
the suction control chamber.
 What would be your priority assessments post-
insertion?

Nursing Management (1 of 5)
 Patient’s clinical status
 Assess:
 Vital signs, lung sounds, pain
 Drainage amount
 Drainage site infection
 Subcutaneous emphysema
 Encourage:
 Deep breathing/Incentive spirometry
 Range-of-motion exercises

 Chest drainage
 Keep below chest
 Mark and measure drainage
• Report greater than 200 mL/hr in first hour and 100
mL/hr thereafter; replace unit when full
 Avoid overturning unit
 Breakage of unit
• Place distal end of chest tube in 2 cm water in sterile
container; replace unit
 No milking or stripping chest tubes

 Wet suction chest drainage
 Monitor:
• Water levels
• Suction at—20 cm H2O
• Gentle bubbling
 Dry suction chest drainage
• Turn dial to ordered amount
• If decrease suction; depress high-negativity vent and
check water level in water-seal chamber

 Chest tube dressings
 Change according to agency policy and procedure
• Petroleum gauze
 Aseptic technique
 Monitor for infection
 Document

 Clamping chest tubes
 Not advocated during transport or disconnection due
to risk for tension pneumothorax
 May clamp briefly to change drainage unit
 Monitor for Complications
 Reexpansion pulmonary edema
 Hypotension
 Severe subcutaneous emphysema

 M.Z. is stabilized and ready for transfer to the
progressive care unit.
 What could the receiving RN delegate to an

unlicensed nursing personnel (UAP) in order to
optimize time management?

Removal of Chest Tubes
 When lungs reexpanded and drainage minimal
 Premedicate prior to removal
 Valsalva maneuver during removal
 Apply occlusive dressing
 Chest x-ray
 Monitor for respiratory distress

Chest Surgery

Chest Surgeries
Most common:
 Decortication
 Exploratory thoracotomy
 Lobectomy
 Lung volume reduction surgery (LVRS)
 Pneumonectomy
 Segmental Resection
 Thoracotomy
 Video-assisted thoracoscopic surgery (VATS)
 Wedge Resection

Surgical Procedures (1 of 2)
 Thoracotomy—surgical incision into the chest
 Median sternotomy —heart
 Lateral thoracotomy—lungs
• Posterolateral
• Anterolateral

Surgical Procedures (2 of 2)
 Video-assisted thoracic surgery (VATS)
• Minimally invasive surgery
• 2-D video image of inside chest cavity
• Diagnosis and treatment of pleura, pulmonary
masses and nodules, mediastinal masses, and
interstitial lung disease; chest trauma
• Advantages: less discomfort, reduced hospital
stay, lower morbidity, fewer complications, faster
return to normal activity

Preoperative Care (1 of 2)
 Assess cardiopulmonary status
 Diagnostic studies
 Chest x-ray, ECG, PFTs, BUN, creatinine, glucose, electrolytes,
coagulation studies, and CBC
 Anesthesia consult
 Smoking cessation
 Teaching:
 PostOp: O2, intubation, IV fluids, blood administration, chest tubes
 Pain management
Splinting
 Exercises: C & DB, IS, ROM
 Reassurance

Postoperative Care (2 of 2)
 Pain management
 PCA, epidural, nerve blocks
 Assess respiratory status
 RR, effort, breath sounds, and sputum volume and
color, chest tubes, and chest x-rays
 Infection
 Temperature
 Incision

Thoracentesis
 Aspiration of intrapleural fluid for diagnosis and
treatment
 1000 to 1200 mL
 Larger volumes result in hypotension, hypoxemia, re-
expansion pulmonary edema
 Chest x-ray: pneumothorax
 Monitor VS, pulse ox, and respiratory distress

Restrictive Respiratory Disorders

Restrictive Respiratory Disorders
 Disorders that impair movement of the chest wall
and diaphragm
 Three categories:
 Extrapulmonary—Lung tissue normal but caused by
CNS, neuro-muscular or chest wall disorders
 Intrapulmonary— Abnormal pleural or lung tissue
disorders
 Hallmark characteristic: reduced forced expiratory
volume (FEV1) on PFTs

Atelectasis
 Collapsed, airless alveoli
 Decreased or absent breath sounds
 Dullness on percussion
 Caused by: secretions obstructing small airways
 At risk: bedridden and postop abdominal and chest
surgery patients
 Prevention and treatment:
• Deep breathing exercises, incentive spirometry, early
mobility

Pleurisy
 Inflammation of the pleura
 Etiology: infection, cancer, autoimmune disorders,
chest trauma, GI disease, and some medications
 Manifestations
• Pain—sharp, worse with inspiration
• Breathing shallow—reduced movement
• Pleural friction rub—peak of inspiration
 Treatment—underlying cause and pain management

Pleural Effusion (1 of 2)
 Abnormal amount of fluid in pleural space; sign of
disease
 Caused by: increased pulmonary capillary pressure,
decreased oncotic pressure, increased pleural
membrane permeability, or lymph flow obstruction
 Types: (depend on protein content)
• Transudative—noninflammatory diseases
• Exudative—inflammatory diseases
 Empyema—purulent fluid in pleural space
• Antibiotics and/or drainage or other procedures

Pleural Effusion (2 of 2)
 Manifestations:
 Dyspnea, cough, sharp chest pain
 Decreased chest movement; dullness, decreased
breath sounds on affected side
 Chest x-ray and CT—location and volume
 Empyema: above manifestation and fever, night
sweats, cough, weight loss
 Interprofessional Care
 Treat underlying cause
 Chemical pleurodesis

Interstitial Lung Diseases

Interstitial Lung Disease (ILD)
 Diffuse parenchymal lung disease
 Greater than 200 disorders caused by inflammation or
scarring (fibrosis) between air sacs
 Two most common:
• Idiopathic pulmonary fibrosis
• Sarcoidosis
 Treatment—reduce exposure or treat underlying
disease
• Corticosteroids, immunosuppressants; transplant

Idiopathic Pulmonary Fibrosis (1 of
2)
 Chronic, progressive disorder; chronic inflammation
and scar tissue in connective tissue; poor prognosis
 Risk factors: smoking; wood & metal dust
 Manifestations: exertional dyspnea; dry,
nonproductive cough, clubbing, crackles
 Progression: weakness, anorexia, weight loss
 Diagnostic Studies:
• PFTs: reduced vital capacity and impaired gas
exchange
• * Open lung biopsy (VATS)—“gold standard”

Idiopathic Pulmonary Fibrosis (2 of
2)
 Treatment
 Corticosteroids and other immune suppressants
 Kinase inhibitor drugs
 Oxygen
 Pulmonary rehabilitation
 Lung transplant
 5 year survival—30s% to 50% after diagnosis

Sarcoidosis
 Chronic, granulomatous disease
 Primary affect on lungs
• Dyspnea, cough, chest pain
 Other: skin, eyes, liver, kidney, heart, lymph nodes
 At risk: blacks and family history
 Treatment—suppress inflammation
 Follow 3 to 6 months: PFTs, chest x-ray, and CT scan
for progression

Vascular Lung Disorders

Pulmonary Edema
 Abnormal accumulation of fluid in alveoli and
interstitial spaces
 Complication of heart and lung diseases
 Most common cause: left-sided HF

Pulmonary Embolism (PE) (1 of 2)
 Etiology and Pathophysiology
 Blockage of one or more pulmonary arteries by
thrombus, fat or air embolus, or tumor tissue
 Clot in venous system into pulmonary circulation then
lodges in small blood vessel and obstructs alveolar
perfusion
 Most often affects lower lobes
239
Pulmonary Embolism (Fig. 27-11)

Pulmonary Embolism (PE) (2 of 2)
 Deep vein thrombosis (DVT)
 Venous thromboembolism (VTE)
 Origination: *deep veins of legs, femoral or iliac veins,
right side of heart (atrial fibrillation) and pelvic veins
• Other: central venous catheters or arterial lines; fat
(fracture); air (IV), vegetation on heart valves, amniotic
fluid, and cancer
 Saddle embolus—large thrombus at arterial
bifurcation

 D.F. is a 74-year-old female who arrives in the
E.D. reporting chest pain and shortness of
breath.
 D.F. was recently discharged from rehab after

undergoing bilateral knee replacements.

 She is 5 ft 2 in tall and weighs 158 pounds.
 Her past medical history is negative except for
mitral regurgitation and heart failure.

 What risk factors does D.F. have for the
development of pulmonary embolism?

Risk Factors for PE
 Immobility or reduced mobility
 Surgery within 3 months (especially pelvic and lower extremity)
 History of VTE
 Cancer
 Obesity
 Oral contraceptives/ hormone therapy
 Smoking
 Prolonged air travel
 Heart failure
 Pregnancy
 Clotting disorders

 You perform a focused assessment on D.F.
 Her vital signs are BP 100/64, HR 110,
Respirations 24, Temp 37.
 She has bibasilar crackles.
 Her breathing appears labored.
 She is somewhat restless and in obvious
distress.

 What manifestations of pulmonary embolism
does D.F. have?

Manifestations
 Depend on type, size, and extent of emboli
• Dyspnea most common (85%); mild-moderate
hypoxemia
• Other: tachypnea, cough, chest pain, hemoptysis,
crackles, wheezing, fever, tachycardia, syncope,
pulmonic heart sound
• Massive PE: change in mental status, hypotension,
impending doom, death

Complications
 Pulmonary infarction
 Occlusion of medium or large-sized vessel,
inadequate collateral blood flow, and preexisting lung
disease results in alveolar necrosis and hemorrhage
which may results in abscess and pleural effusion
 Pulmonary hypertension
 Results from hypoxemia associated with massive
(greater than 50%) or recurrent emboli
 Right ventricular hypertrophy

 What diagnostic tests would you expect to
teach D.F. about?

 D-Dimer
 Elevated with any clot degradation
 False negatives with small PE
 Spiral (helical) CT scan/CT angiography or CTA
 Most common
 Requires IV contrast media
 3-D picture of pulmonary vasculature

 Ventilation-perfusion (V/Q) scan
 Used if patient cannot have contrast
 Two components
• Perfusion scanning—radioisotope injection; images
pulmonary circulation
• Ventilation scanning—radioactive gas inhaled;
distribution of gas in lungs

 Important but not diagnostic
 Arterial blood gases
 Chest x-ray
 Electrocardiogram
 Troponin levels
 b-type natriuretic peptide

 D.F.’s D-Dimer is positive.
 Spiral CT scan confirms the diagnosis of
pulmonary emboli.
 What treatment measures would you expect to
implement for D.F.?

 Goals of treatment
 Adequate tissue perfusion and respiratory function
 Prevent:
• Further growth or extension of lower extremity thrombi
• Prevent embolization from upper or lower extremities to
pulmonary vascular system
• Prevent further recurrence of PE

Interprofessional Care (Table 27-
25)
 Support cardiopulmonary status
 Oxygen: intubation/mechanical ventilation
 Pulmonary hygiene: prevent atelectasis
 Shock: fluids, vasopressors
 HF: diuretics
 Pain: opioids

Drug Therapy
 Anticoagulation - immediate
 Low-molecular-weight heparin (LMWH)
 Unfractionated IV heparin
 Warfarin (Coumadin) or alternative—admission: 3
months (or longer)
 Fibrinolytic agents—dissolve clot
 Tissue plasminogen activator (tPA)
 Alteplase (Activase)

Surgical Therapy
 Pulmonary embolectomy for massive PE
 Hemodynamically unstable patients
 Thrombolytic therapy contraindicated
 Percutaneous catheter embolectomy or
endovascular ultrasound delivered thrombolysis
 Inferior vena cava (IVC) filter
 Prevents migration of clots in pulmonary system

 D.F. is started on a continuous IV drip of
unfractionated heparin at 1000 units/hr.
 Drip will be titrated to therapeutic level using
aPTT levels drawn every 6 hours.
 What nursing interventions would be appropriate
in the care of D.F.?

Nursing Management: PE
 Prevention
 Intermittent pneumatic compression devices
 Early ambulation
 Anticoagulation
 Immediate treatment
 Bed rest in semi-fowler’s position
 Assess cardiopulmonary status
 Administer: oxygen, IV fluids and medications
 Monitor: coagulation and complications

Nursing Management
 Patient support
 Anxiety, pain, dyspnea, fear of death
 Patient education
 Regarding long-term anticoagulant therapy
 Measures to prevent VTE
 Importance of follow-up exams

Pulmonary Hypertension

Pulmonary Hypertension (1 of 2)
 Elevated pulmonary artery pressure due to an
increase in resistance to blood flow through the
pulmonary circulation.
 Mean pulmonary artery pressures
• Normal 12 to16 mm Hg
• Greater than 25 mm Hg at rest
• Greater than 30 mm Hg with exercises
 May be primary disease or secondary complication

Pulmonary Hypertension (2 of 2)
 Five Classes (World Health Organization) based on
causes
 Group 1: medication, specific disease, genetic link or
idiopathic
 Group 2: left-sided heart failure
 Group 3: lungs and hypoxemia
 Group 4: CV system and thromboembolic occlusion
 Group 5: Multifactorial: hematologic or metabolic
involvement

Idiopathic Pulmonary Arterial
Hypertension (IPAH)
 Pulmonary hypertension without known cause
results in right HF and death if untreated
 Etiology and Pathophysiology
 Uncertain; related to connective tissue disease,
cirrhosis, and HIV
 Insult to pulmonary endothelium results in vascular
scarring, endothelial dysfunction, and smooth muscle
proliferation (Fig. 27-12)
 Affects females more than males

Pathogenesis of Pulmonary
Hypertension and Cor Pulmonale

Manifestations and Diagnostic
Studies
 Classic: dyspnea on exertion and fatigue
 Other: exertional chest pain, dizziness, and
syncope, abnormal heart sounds
 Progression: dyspnea at rest, right ventricular
hypertrophy
 Diagnostics
 *Right-sided heart catheterization
 ECG, chest x-ray, PFTs, echo, CT scan

Nursing and Interprofessional
Management (1 of 2)
 Early recognition—stop progression
 Report: unexplained shortness of breath, syncope,
chest discomfort, edema of feet and ankles
 Drug therapy
 Pulmonary vasodilation, reduce right ventricular
overload, and reverse remodeling
 Manage edema
 Prevent thrombi
 Prevent hypoxia

Management (2 of 2)
 Surgical interventions
 Pulmonary thromboendarterectomy (PTE)
 Atrial septostomy (AS)—palliative
 Lung transplant

Secondary Pulmonary Arterial
Hypertension (SPAH)
 Chronic increase in pulmonary artery pressures
from another disease
 Parenchymal lung disease, LV dysfunction,
intracardiac shunts, chronic PE, or systemic
connective tissue disease
 Symptoms: dyspnea, fatigue, lethargy, chest pain; RV
hypertrophy and right-sided heart failure
 Diagnosis—similar to IPAH
 Treatment—treat underlying cause; if irreversible—
IPAH therapies

Cor Pulmonale
 Enlarged right ventricle secondary to disorder of
respiratory system; COPD
 Pulmonary hypertension preexists; HF
 Manifestations
 Exertional dyspnea, tachypnea, cough, fatigue, RV
hypertrophy (ECG), increased intensity in S2 heart
sound, polycythemia
 HF: peripheral edema, weight gain, distended neck
veins, full, bounding pulse, enlarged liver

Management
 Early identification before irreversible heart changes
 Determine and treat underlying cause
 Long-term oxygen
 Other individualized therapies

Lung Transplantation (1 of 4)
 Option for end-stage lung disease
 Treat diseases: COPD, idiopathic pulmonary fibrosis,
cystic fibrosis, IPAH, 1-antitrypsin deficiency
 Preoperative Care
• Evaluation
• Contraindications
• Able to adhere and cope with postoperative regimen
 United Network for Organ Sharing (UNOS)
• Lung Allocation Score (LAS)

 Surgical procedures
 Four types
• Single-lung
• Bilateral lungs
• Heart-lung
• Lobes from living-related donor

 Postoperative Care: ICU
 Ventilator and hemodynamic support
 IV fluids
• Tacrolimus, mycophenolate mofentil, and prednisone
 Nutrition

 Rejection
 Acute: 5 to 10 days
• Fever, fatigue, dyspnea, dry cough, O2 desaturation
 Chronic: Bronchiolitis obliterans (BOS)
• Progressive airflow obstruction unresponsive to
bronchodilators and corticosteroids
 Prevent/treat complications—infection
 Discharge planning/Coordination of care
• Self-care, medication management, contacting
transplant team, pulmonary hygiene, rehabilitation

Lower Respiratory Problems

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Lower Respiratory Problems

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Chapter 27

Lower Respiratory Problems

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2. What type of pneumonia is D.T. likely

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 Normal breathing patterns

 Normal chest x-ray

 Normal WBC count

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 She is hemodynamically stable and

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 What important teaching should you provide to

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