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Chronic Respiratory Disorders

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Title: Chronic Respiratory Disorders


1
Chapter 31
  • Chronic Respiratory Disorders

2
Learning Objectives
  • Identify examples of chronic inflammatory,
    obstructive, and restrictive pulmonary diseases.
  • Explain the relationship between cigarette
    smoking and chronic respiratory disorders.
  • For selected chronic respiratory disorders,
    describe the pathophysiology, signs and symptoms,
    complications, diagnostic measures, and medical
    treatment.
  • Assist in developing a nursing care plan for the
    patient who has a chronic respiratory disorder.

3
Asthma
4
Pathophysiology
  • Potentially reversible obstructive airway
    disorder airway inflammation and
    hyperresponsiveness

5
Pathophysiology Acute Episode
  • Begins when triggers activate the inflammatory
    process
  • Airways constrict and become edematous
  • Mucous secretion increases, forming plugs in the
    airways, and tenacious sputum is produced
  • Obstruction causes air to be trapped in the
    alveoli, creating a ventilation-perfusion
    mismatch
  • Effect is hypoxemia with compensatory
    hyperventilation
  • Acute episodes begin within 30 to 60 minutes
    after exposure to trigger and resolve 30 to 90
    minutes later

6
Figure 31-1
7
Pathophysiology
  • Late phase
  • Begins 5 to 6 hours after the early phase
    response
  • Red and white blood cells infiltrate swollen
    tissues of the airways
  • During this phase, which lasts several hours or
    days, the airways are hyperreactive (very
    sensitive)
  • Risk for another episode until phase subsides
  • When no specific trigger can be identified, the
    patient may be said to have intrinsic asthma
  • Asthma with known triggers extrinsic asthma

8
Signs and Symptoms
  • Dyspnea, productive cough, use of accessory
    muscles of respiration, audible expiratory
    wheezing, tachycardia, and tachypnea

9
Medical Diagnosis
  • Health history, the physical examination, and the
    pulmonary function test results

10
Medical Treatment
  • Bronchodilators
  • Anti-inflammatory drugs

11
Figure 31-2
12
Assessment
  • Essential information (medications, allergies,
    known cardiac disease, sleep disruption)
    immediately take steps to relieve symptoms
  • Health history
  • Frequency and severity of attacks, the factors
    known to trigger attacks, effect of condition on
    patients life, strategies used to manage the
    condition, sources of stress and support, and
    patients knowledge about asthma and its treatment

13
Assessment
  • Physical examination
  • Measurement of vital signs and auscultation of
    lung sounds
  • Assess skin color and respiratory effort

14
Interventions
  • Ineffective Breathing Pattern
  • Impaired Gas Exchange
  • Anxiety

15
Chronic Bronchitis and Emphysema
16
Pathophysiology
  • Chronic bronchitis
  • Bronchial inflammation increased production of
    mucus and chronic cough that persist for at least
    3 months of the year for 2 consecutive years and
    by impaired ciliary action
  • Cause inhaled irritants, e.g., cigarette smoke
  • Cor pulmonale right-sided heart failure
    secondary to pulmonary disease

17
Figure 31-3
18
Pathophysiology
  • Emphysema
  • Degenerative, nonreversible disease enlargement
    of the airways beyond the terminal bronchioles
  • Centrilobular emphysema
  • Associated with cigarette smoking affects mainly
    the respiratory bronchioles
  • Panlobular emphysema
  • Affects the respiratory bronchioles and the
    alveoli

19
Figure 31-4
20
Complications
  • Respiratory failure
  • Factors infection, air pollution, continued
    smoking, left ventricular failure, myocardial
    infarction, pulmonary embolism, spontaneous
    pneumothorax, and adverse effects of drugs

21
Signs and Symptoms
  • Chronic bronchitis
  • Productive cough, exertional dyspnea, and
    wheezing
  • Emphysema
  • Dyspnea on exertion
  • Increased anteroposterior diameter

22
Figure 31-5
23
Figure 31-6
24
Figure 31-7
25
Medical Diagnosis
  • Patients health history and physical examination
  • Pulmonary function tests
  • Computed tomography (CT) scan

26
Medical Treatment
  • Drug therapy
  • Goals improved ventilation and removal of
    secretions
  • Bronchodilators
  • Corticosteroids

27
Medical Treatment
  • Oxygen therapy
  • Initial is usually 1 to 3 L/minute
  • Chest physiotherapy
  • Exercise
  • Nutrition
  • Supplementary feedings may be needed
  • Good hydration
  • Treatment of respiratory failure
  • Oxygen therapy, aerosol bronchodilators, chest
    physiotherapy, and mechanical ventilation

28
Surgical Treatment
  • Lung volume reduction surgery (LVRS)
  • Up to 30 of hyperinflated lung tissue excised to
    improve mechanics of breathing, enabling patient
    to breathe more deeply
  • Bullectomy (removal of bullae)
  • Lung transplantation

29
Assessment
  • Describe the presenting symptomsoften dyspnea,
    cough, chest pain, or a combination of these
  • Obtain a complete medical history
  • List of current medications and drug allergies

30
Assessment
  • Physical examination
  • Posture, color, respiratory effort, and use of
    accessory muscles of respiration measure vital
    signs
  • Hypoxemia restlessness, confusion, and lethargy
  • Inspect neck for distention of veins
  • Shape of the thorax for the classic barrel chest
  • Auscultate lung fields for diminished breath
    sounds
  • Inspect the nails for clubbing, pallor, or
    cyanosis
  • Inspect and palpate the feet and ankles for
    edema note muscle wasting

31
Interventions
  • Impaired Gas Exchange
  • Ineffective Airway Clearance
  • Anxiety
  • Imbalanced Nutrition Less Than Body Requirements
  • Risk for Infection
  • Activity Intolerance
  • Decreased Cardiac Output

32
Figure 31-8
33
Bronchiectasis
  • Abnormal dilation/distortion of bronchi and
    bronchioles usually confined to one lung lobe or
    segment
  • Follows recurrent inflammatory conditions,
    infections, or obstructions but is sometimes
    congenital
  • Signs coughing, production of large amounts of
    purulent sputum
  • Also fever, hemoptysis, nasal stuffiness, sinus
    drainage, fatigue, and weakness
  • Goals control symptoms and prevent spread
  • Treatment antibiotic therapy, bronchodilators,
    chest physiotherapy, and oxygen therapy

34
Cystic Fibrosis
  • Hereditary disorder characterized by dysfunction
    of the exocrine glands and production of thick,
    tenacious mucus
  • Cough is the first pulmonary symptom
  • Becomes productive of thick, purulent sputum
    obstructs airways
  • Results in obstruction of the pancreatic ducts so
    that pancreatic enzymes cannot be delivered to
    the GI tract

35
Cystic Fibrosis
  • Stools become bulky and foul smelling
  • Lose more salt in sweat than normal at risk for
    salt depletion, especially in hot environments
  • Over years, symptoms progress increased dyspnea,
    decreased exercise tolerance, and weight loss
  • Airway obstruction and decreased resistance to
    infections lead to chronic bacterial infections,
    emphysema, atelectasis, and respiratory failure

36
Cystic Fibrosis
  • Treatment
  • Pancreatic enzyme replacement, chest
    physiotherapy, and aerosol and nebulizer
    treatments to reduce mucus viscosity
  • Infections treated with antibiotics

37
Cystic Fibrosis
  • Nursing care
  • To clear airway administer prescribed
    medications, maintain hydration, and perform
    chest physiotherapy
  • Prevent infection with medical asepsis and
    protect patient from others with infections
  • Maintain adequate nutrition administer
    pancreatic enzymes as ordered, allow for rest
    around mealtimes, and encourage to consume
    adequate nutrients

38
Tuberculosis
39
Etiology and Risk Factors
  • An infection caused by Mycobacterium
    tuberculosis, an acid-fast aerobic bacterium
  • Spread by droplets from infected people during
    coughing, laughing, sneezing, and singing
  • Anyone may become infected, but most healthy
    people not through brief contact
  • At increased risk elderly, economically
    disadvantaged and homeless, substance abusers,
    children younger than 5 years, the
    immunosuppressed, racial and ethnic groups

40
Pathophysiology
  • Most people do not acquire active (symptomatic,
    progressive) tuberculosis
  • Bodys immune response attempts to destroy the
    infecting organisms, but some may escape into the
    lymph nodes or throughout the body
  • The site of the primary infection may undergo
    necrotic degeneration

41
Pathophysiology
  • Cavities develop that are filled with infectious
    material, which eventually liquefies and is
    coughed up as sputum
  • In some, infectious process progresses, and
    active tuberculosis develops
  • It is possible for inactive bacteria to be
    reactivated, causing illness later

42
Signs and Symptoms
  • Cough, night sweats, chest pain and tightness,
    fatigue, anorexia, weight loss, and low-grade
    fever

43
Medical Diagnosis
  • History and physical examination
  • Sputum cultures, acid-fast smears of potentially
    infected body fluids, tuberculin skin tests, and
    chest radiographs

44
Medical Treatment
  • Common preventive treatment is isoniazid therapy
    for 9 to 12 months
  • Individuals with inactive tuberculosis may be
    treated with INH alone, INH with rifampin, or
    rifampin with pyrazinamide

45
Assessment
  • A complete health history and a physical
    examination

46
Interventions
  • Impaired Gas Exchange
  • Social Isolation
  • Risk for Injury
  • Fatigue
  • Imbalanced Nutrition Less Than Body Requirements
  • Ineffective Therapeutic Regimen Management

47
Interstitial Lung Disease
  • Inflammation of the lower respiratory tract and
    thickening and fibrosis of the alveolar walls
    render the alveoli nonfunctional
  • May be caused by inhaled substances or connective
    tissue disorders sometimes no specific cause
    identified
  • Examples idiopathic pulmonary fibrosis
    (occupational lung diseases), sarcoidosis

48
Idiopathic Pulmonary Fibrosis
  • Pathophysiology
  • Formation of scar tissue in lung tissue after
    inflammation or irritation
  • Cigarette smoking, frequent aspiration, or
    exposure to environmental or occupational
    substances
  • Complications
  • Pulmonary hypertension, cor pulmonale, and
    ventilatory failure

49
Idiopathic Pulmonary Fibrosis
  • Signs and symptoms
  • Nonproductive cough and progressive dyspnea
  • Inspirational crackles heard in the lungs on
    auscultation
  • Clubbing of the fingertips

50
Idiopathic Pulmonary Fibrosis
  • Medical treatment
  • Corticosteroids, bronchodilators, and oxygen
    therapy
  • Also cytotoxic drugs and antifibrotic agents
  • Interventions
  • Similar to those described for the patient with
    COPD

51
Occupational Lung Diseases
52
Acute Respiratory Irritation
  • Inhalation of gases such as ammonia or chlorine
  • Effects usually temporary, but if the lower
    airways are affected, pulmonary edema or alveolar
    damage and airway obstruction
  • May have coughing, wheezing, and dyspnea
  • Symptoms resolve within a few days to several
    weeks usually no permanent lung damage
  • Treatment managing symptoms and avoiding exposure

53
Occupational Asthma
  • Inhalation of plant or animal proteins cause an
    allergic reaction
  • Treatment same as for bronchial asthma
  • Initial acute symptoms last only a few hours, but
    patient may have hyperreactive airway for years
  • This means that future exposure to irritants may
    trigger acute asthmatic symptoms
  • Patient should avoid continued exposure to the
    offending substance

54
Hypersensitivity Pneumonitis
  • Allergic inflammatory response of the alveoli to
    inhaled organic particles
  • May resolve in a few days, or patient may
    contract pulmonary edema or interstitial fibrosis
    with permanent restrictive or restrictive-obstruct
    ive disease
  • Treated with corticosteroids and avoidance of
    irritants respiratory support may be needed if
    symptoms are severe

55
Pneumoconiosis
  • Caused by inhalation of various dusts
  • In response to repeated exposure to silica,
    asbestos, or coal dust characterized by diffuse
    pulmonary fibrosis and restrictive lung disease
  • Aggravated by cigarette smoking advised to avoid
    offending dust and cigarette smoke
  • Otherwise, treatment is symptomatic

56
Chronic Restrictive Pulmonary Disorders
57
Sarcoidosis
  • Pathophysiology
  • Inflammatory condition affects the skin, eyes,
    lungs, liver, spleen, bones, salivary glands,
    joints, and heart
  • An unknown factor triggers a series of immune
    processes leads to formation of clusters of
    cells and debris in affected tissues called
    granulomas
  • Signs and symptoms
  • Some have no symptoms, others experience dry
    cough, dyspnea, chest pain, hemoptysis, fatigue,
    weakness, weight loss, and fever

58
Sarcoidosis
  • Medical diagnosis
  • Chest radiography, pulmonary function tests, and
    flexible bronchoscopy with transbronchial lung
    biopsy
  • Medical treatment
  • If patient is asymptomatic, no treatment is
    indicated
  • 6- to 12-month course of systemic corticosteroids
  • Methotrexate used as an alternative to
    corticosteroids
  • Lung transplantation only option for patients
    with end-stage disease who do not respond to drug
    therapy

59
Sarcoidosis
  • Nursing care
  • Monitoring for progressive dysfunction and
    teaching about corticosteroid therapy
  • Care of the patient with severe pulmonary
    symptoms is similar to that for patients with COPD

60
Lung Cancer
  • Etiology and risk factors
  • Leading cause of cancer death in the United
    States
  • Cigarette smoking leading cause
  • Risk increased more for smokers exposed to other
    carcinogenic substances, such as arsenic,
    asbestos, and radioactive materials
  • Evidence that secondhand smoke a threat to
    nonsmokers

61
Lung Cancer
  • Pathophysiology
  • Small cell (oat cell) lung carcinoma (SCLC)
  • Nonsmall cell lung carcinoma (NSCLC)
  • Squamous cell carcinomas, adenocarcinomas, large
    cell carcinomas, and bronchial carcinoids
  • Small cell and large cell undifferentiated
    carcinomas grow rapidly other lung cancers grow
    slowly
  • All can metastasize to other body organs
  • SCLCs, which grow rapidly, tend to metastasize
    early
  • Can invade the pericardium, causing pericardial
    effusion and possibly triggering dysrhythmias

62
Lung Cancer
  • Signs and symptoms
  • Persistent cough, hemoptysis, chest pain, and
    recurring pneumonia or bronchitis
  • May have dyspnea, weight loss, and pain in the
    shoulder, arm, or hand
  • Other signs and symptoms may be related to
    metastatic lesions

63
Lung Cancer
  • Medical diagnosis
  • Radiographic procedures (chest radiography, CT
    scan, MRI), fiberoptic bronchoscopy, sputum
    cytology studies, and biopsy of tissue obtained
    through bronchoscopy, percutaneous transthoracic
    fine-needle biopsy, thoracotomy, or other methods
  • Radionuclide scans of bones, liver, or brain to
    detect metastatic lesions

64
Lung Cancer
  • Medical treatment
  • Radiotherapy
  • Chemotherapy
  • Targeted biologic therapies
  • Surgical treatment
  • Wedge resection, sleeve lobectomy, segmental
    resection, lobectomy, or pneumonectomy

65
Figure 31-9
66
Lung Cancer
  • Nursing care
  • Nurses must continue to educate the public about
    the dangers of cigarette smoking to help
    eliminate the primary cause of lung cancer

67
Extrapulmonary Disorders
  • Chest deformities interfere with lung expansion
  • Neuromuscular diseases such as myasthenia gravis
    and amyotrophic lateral sclerosis affect the
    muscles of respiration
  • Head or spinal cord injuries can disrupt the
    breathing center in the brain or the neural
    control of the diaphragm
  • Heart failure with pulmonary edema fills lungs
    with fluid, interfering with the exchange of gases

68
Figure 31-10
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