Management of Patient with Chest and Lower Respiratory Tract

Disorders

Atelectasis

» Atelectasis refers to closure or collapse of alveoli

» Atelectasis may be acute or chronic and may cover a broad range of pathophysiologic
changes, from microatelectasis (which is not detectable on chest x-ray) to
macroatelectasis with loss of segmental, lobar, or overall lung volume

» The most commonly described atelectasis is acute atelectasis, which occurs frequently
in the postoperative setting or in people who are immobilized and have a shallow,
monotonous breathing pattern.

» Atelectasis is also observed in patients with a chronic airway obstruction that impedes
or blocks airflow to an area of the lung

PATHOPHYSIOLOGY

ATELECTASIS

Excessive bronchial secretions/foreign body aspirations/bronchial neoplasm

Obstructed Alveoli

Impedes the passage of air in and out of the alveoli

Alveolar air was absorbed in the bloodstream

Alveoli become airless and subsequently collapse chest pain

Irregular breathing patterns

Collapse of Parts of a Lung

Clinical Manifestations

» The development of atelectasis usually is insidious. Signs and symptoms include cough,
sputum production, and low-grade fever

» In acute atelectasis involving a large amount of lung tissue (lobar atelectasis), marked
respiratory distress may be observed.

» In chronic atelectasis, signs and symptoms of chronic atelectasis are similar to those of
acute [Link] the alveolar collapse is chronic, infection may occur distal to
the obstruction.

Preventing atelectasis

» Change patient’s position frequently, especially from supine to upright position, to

promote ventilation and prevent secretions from accumulating.

» Encouraged early mobilization from bed to chair followed by early ambulation.

» Encouraged appropriate deep breathing and coughing to mobilize secretions and

prevent them from accumulating.

» Teach / reinforce appropriate technique for incentive spirometry.

» Administer prescribed opioids and sedatives judiciously to prevent respiratory

depression.

» Perform postural drainage and chest percussion, if indicated.

» Institute suctioning to remove tracheobronchial secretions, if indicated.

Management

»The goal in treating the patient with atelectasis is to improve ventilation and remove
secretions.

»The strategies to prevent atelectasis, which include frequent turning, early ambulation,
lung volume expansion maneuvers (eg, deep-breathing exercises, incentive spirometry),
and coughing also serve as the first-line measures to minimize or treat atelectasis by
improving ventilation.
» If the cause of atelectasis is bronchial obstruction from secretions, the secretions must
be removed by coughing or suctioning to allow air to re-enter that portion of the lung.

» Chest physical therapy may also be used to mobilize secretions.

» Management of chronic atelectasis focuses on removing the cause of the obstruction of

the airways or the compression of the lung tissue

ACUTE TRACHEOBRONCHITIS

» Acute tracheobronchitis, an acute in flammation of the mucous membranes of the

trachea and the bronchial tree, often follows infection of the upper respiratory tract.

» Adequate treatment of upper respiratory tract infection is one of the major factors in the
prevention of acute bronchitis.

» Aside from infection, inhalation of physical and chemical irritants, gases, and other air
contaminants can also cause acute bronchial irritation.

Pathophysiology

TRACHEOBRONCHITIS

Presence of microorganism
(Streptococcus pneumoniae, Haemophilus influenzae, and Mycoplasma pneumonia)

Invades respiratory mucosa

Becomes inflamed and produces mucopurulent sputum

Hyperemia and edema of Mucus Goblet cell

Lung mucous membranes Hypersecretion Metaplasia
Medical Management
» Antibiotic treatment may be indicated depending on the symptoms, sputum purulence,
and results of the sputum culture.

» Expectorants may be prescribed, although their efficacy is questionable. Fluid intake is

increased to thin the viscous and tenacious secretions.

» In most cases, treatment of tracheobronchitis is largely symptomatic. The patient is

advised to rest. Increasing the vapor pressure (moisture content) in the air will reduce
irritation.

» Cool vapor therapy or steam inhalations may help relieve laryngeal and tracheal
irritation.

» Moist heat to the chest may relieve the soreness and pain.

» Mild analgesics or antipyretics may be indicated.

Nursing Management
» A primary nursing function is to encourage bronchial hygiene, such as increased fluid
intake and directed coughing to remove secretions.

» The nurse encourages and assists the patient to sit up frequently to cough effectively
and to prevent retention of mucopurulent sputum.

» Fatigue is a consequence of tracheobronchitis; therefore, the nurse cautions the patient

against overexertion, which can induce a relapse or exacerbation of the infection.

» The patient is advised to rest.

PNEUMONIA
» Pneumonia is an inflammation of the lung parenchyma caused by a various
microorganisms including bacteria, mycobacteria chlamydia mycoplasma, fungi,
parasites and viruses.

» Pneumonitis is a more general term that describes an inflammatory process in the lung
tissue that may predispose or place the patient at risk for microbial invasion.

»Pneumonia is the most common cause of death from infectious diseases

Classification

» Classically, pneumonia has been categorized into one of four categories: bacterial or
typical, atypical, anaerobic/, and opportunistic.

» A more widely used classifications scheme categorizes the major pneumonias as

community acquired pneumonia, (CAP) hospital acquired pneumonia (HAP), pneumonia
in the immunocompromised host, and aspiration pneumonia.

Community-Acquired pneumonia
» (CAP) occurs either in the community setting or within the first 48 hours of
hospitalization or institutionalization.

» The causative agents for CAP that requires hospitalization are most frequently requiring
[Link], [Link], Legionella, Pseudomonas aeruginosa, and other gram-
negative rods.

» Pneumonia caused by [Link] (pneumococcus) is the most common in people

younger than 60 of age

» Mycoplasma pneumonia, another type of CAP, occurs most often in older children and
young adults and is spread by infected respiratory droplets through person-to-person
contact.

» [Link] is another cause of CAP. It frequently affects elderly people and those
with co morbid illnesses (eg, chronic obstructive pulmonary disease [COPD], alcoholism,
and diabetes mellitus).

» The chief causes of viral pneumonia in the immunocompetent adult are influenza
viruses’ types A and B, adenovirus, Para influenza virus, coronavirus, and varicella-
zoster virus

Hospital-acquired pneumonia
» (HAP), also known as nosocomial pneumonia, is defined as the onset of pneumonia
symptoms more than 48 hours after admission in patients with no evidence of infection at
the time of admission

» Ventilator –associated pneumonia is defined as bacterial pneumonia that develops in

patients with acute respiratory failure who have been receiving mechanical ventilation for
at least 48 hours.
» These respiratory infections occur when at least one of three conditions exists: host
defenses are impaired, an inoculum of organisms reaches the lower respiratory tract and
overwhelms the host; defenses or a highly virulent organism is present.
» HAP(eg,therapeutic agents leading to central nervous system depression with decreased
ventilation, impaired removal of secretions, or potential aspiration;

» HAP is associated with a high mortality rate, in part because of the virulence of the
organisms, their resistance to antibiotics, and the patient’s underlying disorder.

» The usual presentation of HAP is a new pulmonary infiltrate on chest x-ray combined
with evidence of infection such as fever, respiratory symptoms, purulent sputum, and
leukocytosis.

Pneumonia in the Immunocompromised Host

» pneumonia in the immunocompromised host is pneumocystis pneumonia, fungal

pneumonias, and mycobacterium tuberculosis.

» Immunocompromised states occur with the use of corticosteroids or other

immunosuppressive agents,chemotherapy,nutritional depletion, use of broad-spectrum
antimicrobial agents, AIDS, genetic immune disorders,and long-term advanced life-
support technology (mechanical ventilation).

Aspiration pneumonia

» Aspiration pneumonia refers to the pulmonary consequences resulting from the entry of
endogenous or exogenous substances into the lower airway.

» Aspiration pneumonia may occur in the community or hospital setting; common

pathogens are [Link], [Link], and [Link].

» substances may be aspirated into the lung, such as gastric contents, exogenous chemical
contents, or irritating gases.
Pathophysiology

PNEUMONIA

Presence of Pneumococcus and other various agents

Lungs becomes inflamed

Air sacs are filled with pus or exudates- air is excluded

Interference in ventilation and diffusion of air

Lungs becomes consolidated

Chest pain/dyspnea chills fever paroxysmal rusty-colored

Or chocking sputum (considered
Cough to be the
path gnomonic
sign)
Risk Factors

» Pneumonia occurs in patient with certain underlying disorders such as heart failure,
diabetes alcoholism COPD and AIDS.

Clinical Manifestations
» The patient with streptococcal (pneumococcal) pneumonia usually has a sudden onset
of chills, rapidly rising fever (38.5 to 40.5), and pleuritic chest pain that is aggravated by
deep breathing and coughing.

» The patient is severely ill, with marked tachypnea (25 to 45 breaths/min), accompanied
by other signs of respiratory distress (eg, shortness of breath, use of accessory muscles in
respiration).

» The predominant symptoms may be headache, low-grade fever, pleuritic pain, myalgia,
rash, and [Link] a few days, mucoid or mucopurulent sputum is expectorated.

Assessment and Diagnostic Findings

» The diagnosis of pneumonia is made by history (particularly of a recent respiratory tract

infection), physical examination, chest x-ray studies, blood culture (bloodstream
invasion, called bacteremia, occurs frequently), and sputum examination.

» More invasive procedures may be used to collect specimens

» Bronchoscopy is often used in patients with acute severe infection, patients.

Other Therapeutic regimens

» Antibiotics are ineffective in viral upper respiratory tract infections and pneumonia and
their use may be associated with adverse effects.

» Antibiotics are indicated with a viral respiratory infection only if a secondary bacterial
pneumonia, bronchitis, or sinusitis is present.

» Treatment of viral pneumonia is primarily supportive. Antipyretics may be used to treat

headache and fever; antitussive medications may be used for the associated cough.

» Antihistamines may provide benefit with reduced sneezing and rhinorrhea.

»If hypoxemia develops, oxygen is administered.

Complications
» Shock and respiratory failure

» Atelectasis and Pleural effusion

» Super infection

Nursing interventions
» Improving airway patency

»Promoting rest and conserving energy

»Promoting fluid intake

»Maintaining nutrition

»promoting patient’s knowledge

»monitoring and managing potential complication

»promoting home and community-based care

Severe acute respiratory syndrome

»Severe acute respiratory syndrome (SARS) is a viral respiratory illness caused by a

corona virus

» SARS- associated corona virus is transmitted via respiratory droplets when an infected
person coughs or sneezes; the droplets may be deposited on the mucous membrane
(mouth, nose, eyes) of a nearby person.

»SARS are a high fever in association with headache, overall discomfort and body aches.
Approximately 10% to 20% of patients develop diarrhea. After 2 to 7 days, cough may
develop, which often includes progressive hypoxemia and subsequent pneumonia

» Specific strategies for SARS should be in place regarding use of negative pressure
isolation rooms, personal protective equipment, hand hygiene, environmental cleaning
and disinfection techniques and source control measures to contain patients secretions
PULMONARY TUBERCULOSIS

» Tuberculosis (TB) is an infectious disease that primarily affects the lung parenchyma.

» It also may be transmitted to other parts of the body, including the meninges, kidneys,
bones, and lymph nodes.

» The primary infectious agent, Mycobacterium tuberculosis, is an acid-fast aerobic rod

that grows slowly and is sensitive to heat and ultraviolet light

» Mycobacterium bovis and Mycobacterium avium have rarely been associated with the
development of a TB infection.
» TB is a worldwide public health problem, and mortality and morbidity rates continue to
rise.

» TB is closely associated with poverty, malnutrition, overcrowding, substandard

housing, and inadequate health care.

Transmission
» TB spreads from person to person by airborne transmission

» An infected person releases droplet nuclei (generally particles 1 to 5 micrometers in

diameter) through talking, coughing, sneezing, laughing, or singing.

Risk Factors for TUBERCULOSIS

» Close contact with someone who has active TB

» Immunocompromised status

» Substance abuse

» Any person without adequate health care

» Preexisting medical conditions or special treatment

» Immigration from countries with a high prevalence of TB

» Institutionalization

» Living in overcrowded, substandard housing

» Being a health care worker performing high-risk activities:

Pathophysiology

TUBERCULOSIS

Mycobacterium bacilli gains access into the body (inhalation)

Invades the respiratory tract through lymph nodes and blood streams

Produces original lesions, the tubercle

Granulomas, surrounded by macrophages form a protective wall

This mass becomes dormant

After 1st exposure, the person then develop an active disease

(Due to compromised immune system)

Commonly occurs in the lungs

(Usually in the apical or posterior segments of the upper lobes,
or the superior segments of the lower lobes)

Clinical Manifestations
» The signs and symptoms of pulmonary TB are insidious. Most patients have a low-
grade fever, cough, night sweats, fatigue, and weight loss.

» Hemoptysis also may occur.

Assessment and Diagnostic Findings

» A complete history, physical examination, tuberculin skin test, chest x-ray, acid-fast
bacillus smear, and sputum culture are used to diagnose TB.

» If the person is infected with TB, the chest x-ray usually reveals lesions in the upper
lobes and the acid-fast bacillus smear contains mycobacterium.

NURSING INTERVENTIONS

» Promoting airway clearance

» Advocating adherence to treatment regimen

» Promoting activity and adequate nutrition

» Monitoring and managing potential complications

» Promoting home and community based care

Lung Abscess

» A lung abscess is a localized necrotic lesion of the lung parenchyma containing

purulent material that collapses and forms a cavity.

» Generally caused by aspiration of anaerobic bacteria.

» Patients who have impaired cough reflexes and cannot close the glottis, and those with
swallowing difficulties, are at risk for aspirating foreign material and developing a lung
abscess.

» Other at-risk patients include those with central nervous system disorders (seizure,
stroke), drug addiction, alcoholism, esophageal disease, or compromised immune
function.

» Most lung abscesses are a complication of bacterial pneumonia or are caused by

aspiration of oral anaerobes into the lung.

Pathophsiology
LUNG ABSCESS

Complication of other condition

(Maybe pneumonia, aspiration, obstruction of the bronchi or neoplasm)

Necrosis of the pulmonary tissue and formation of cavities

Cough with purulent Fever with night Chest pain Shortness of

Sputum Sweats breath

Clinical Manifestations

» The clinical manifestations of a lung abscess may vary from a mild productive cough to
acute illness.

» Most patients have a fever and a productive cough with moderate to copious amounts
of foul smelling, often bloody, sputum.

» Leukocytosis may be present. Pleurisy or dull chest pain, dyspnea, weakness, anorexia,
and weight loss are common.

Prevention

» Appropriate antibiotic therapy before any dental procedures in patients who must have
teeth extracted while their gums and teeth are infected

» Adequate dental and oral hygiene, because anaerobic bacteria play a role in the
pathogenesis of lung abscess

» Appropriate antimicrobial therapy for patients with pneumonia

Medical Management
» The findings of the history, physical examination, chest x-ray, and sputum culture
indicate the type of organism and the treatment required.

» Adequate drainage of the lung abscess may be achieved through postural drainage and
chest physiotherapy.

» The patient should be assessed for an adequate cough. A few patients need a
percutaneous chest catheter placed for long-term drainage of the abscess.

»A diet high in protein and calories is necessary because chronic infection is associated
with a catabolic state, necessitating increased intake of calories and protein to facilitate
healing.

Nursing Management
» The nurse administers antibiotics and intravenous therapies as prescribed and monitors
for adverse effects.

» Chest physiotherapy is initiated as prescribed to facilitate drainage of the abscess.

» The nurse teaches the patient to perform deep-breathing and coughing exercises to help
expand the lungs.

» The nurse also offers emotional support because the abscess may take a long time to
resolve.