Respiratory 3:

More on the Lower

Respiratory System

Mary J. Aigner RN, MSN, FNPC

What problems?

The 3 P’s: Pleurisy, Pleural Effusions,

and Pneumonia
Let’s start with the Pleurisy

 Your textbook
doesn’t say much
about this problem

 See Table 34-5,

page 634

 Textbook lists it as
a common
complication of
pneumonia
So what is it?

 Inflammation of the
linings around the
lung
 What are they?
– One covers the lung
- visceral
– One covers the
inner chest wall -
parietal
– Both lubricated by
pleural fluid
Pleurisy
 Sometimes called “pleuritis”
 Lung’s pain fibers are located in the
pleura.
– As tissue becomes inflamed
 Sharp pain occurs
 Worse with inspiration
 Chest pain common symptom

 Other symptoms
– Shortness of breath
– Cough
– Chest tenderness
– May have fluid accumulate in space between
pleura
 Called pleural effusion
More on pleurisy - Causes

 Infections  Cancers
– Bacterial – Lung, breast, etc.
 Including TB  Tumors of pleura
– Fungus – Mesothelioma
– Parasites – Sarcoma
– Viruses  Congestion
 Inhaled chemicals – HF
or toxic substances  Pulmonary Embolism
 Collagen vascular  Trauma
diseases – Eg. Rib fx
– Lupus – Irritation from chest
– RA tubes
 Lymph channel
obstruction
– Usu from tumors Causes cont:
 Certain drugs
– Cause Lupus-like
syndromes
 Hydralazine
 Procan
 Dilantin etc.
 Abd conditions
– Pancreatitis
– Cirrhosis of the liver
 Alcoholics at risk
 Lung infarction
– Usu 2nd poor blood Fibrous tumor of pleura
supply
Ever hear of Mesothelioma?

 Caused by
asbestos
(inhalation)
 Results in cancer
of pleura - the
lining
 Radical surgery to
remove tumor is
sometimes done
How is pleurisy diagnosed?

 Pain is distinctive
– In chest, usu sharp, worsens with resp
– Can often hear pleural friction rub
 Differsfrom pericarditis which is synchronized
with heartbeat
 Breath sounds may be diminished if large
amount pleural fluid present
– Dull to percussion
 CXR
 U/S
 CT Scan to detect trapped pockets of fluid
Removal of fluid
– “transudative fluid”
 Normal levels
 Aspirated with needle  Indicates HF, liver
and syringe (called???) and kidney disease
– Check for color,
consistency, and clarity
 Pulmonary emboli
(lab) can cause either
– Called “exudate” if high in type of fluid
protein, low in sugar, high
in LDH enzyme, and WBC
count
– (indicates inflammation)
– Caused by infection (eg.
Pneumonia), cancer, lupus,
RA. TB
Treatment of Pleurisy
 Pain
– External splinting
– Pain medication
 Treat underlying cause
– Thoracentesis to remove
fluid from pleural cavity
 If infected - RX ATB
– Pus?
 Chest drain inserted
– Adhesions?
 Decortication done - removes
scar tissue, pus, & debris
– Complicated?
 Open surgical procedure -
thoracotomy
How would you care for
someone with pleurisy?
 Count off 1 thru 8
 Come up with a l Infections
basic care plan for l Cirrhosis of Liver
pleurisy related to l Breast Ca
the cause (see l Dilantin
right) l Rib Fracture
 Consider:
l PE
l Mesothelioma
– Prevention
– Symptom RX
l CHF
– Nutrition
– Other Interventions
– How to Evaluate
What’s the difference … ?

 Infiltrate
versus
 Pleural effusion

 Is one worse than

the other?

 Is one harder to
RX?
Let’s check out some images

 [Link]
What are some treatments?

 Pericardial Window: A procedure in which an

opening is made in the pericardium to drain fluid
that has accumulated around the heart. A
pericardial window can be made via a small incision
below the end of the breastbone (sternum) or via a
small incision between the ribs on the left side of
the chest.
 Pericardiectomy: The surgical removal of
part of the pericardium - membrane surrounding
the heart. May be performed for chronic
pericarditis (inflammation of pericardium).
 Pleurodesis or Pleural Sclerosis:
pleural space is sclerosed to prevent recurrence of
malignant pleural effusion
 Thoracentesis
 Tube thoracostomy
Defined as:

 Excess fluid in
lungs
– 2nd inflammatory
process
 Triggers:
– Infections
– Irritating agents
 Two categories
– CAP
– HAP (nosocomial)
Pathophys (page 633)

 Inflammation occurs where?

– Interstitial spaces, alveoli, often broncioles
 Organisms penetrate airway mucosa
– Multiple in alveolar spaces
– WBCs migrate to area of infection
 Causes local capillary leak, edema, exudate
 Fluids collect in & around alveoli
 Alveolar walls thicken

 What does this do to gas exchange?

More …

 RBCs and fibrin also move into alveoli

– Capillary leakage spreads infection to
other lung areas
– Sepsis can result if gets in bloodstream
– Empyema results if infection gets into
pleural cavity
 Fibrin & edema (from inflammation)
– Stiffen lungs - reduce compliance
< lung capacity (VC)
– Atelectasis (alveolar collapse) can occur
 Less blood moves through lungs = < O2
More:
 Lobar pneumonia
with consolidation
– Solidifies - lack of air
space
– Occurs in a segment
or lobe
 Bronchopneumonia
– Scattered patches
around bronchi
 Extent depends on
host defenses

– Which means
what?
Risk Factors (page 634)

 Table 34-3

 Common
organisms
– Table 34-4 (p 634)

 HAP more likely

resistant to ATB

– WHY?
Health Promotion/
Disease Prevention

 Pneumonia  Assessment
Vaccine – What are S&S?
– Most common – What history do
pneumococcal you need to take?
organisms – What diagnostics
covered might be done?
 Client education  Why?

important – Why might you

– See P 634 find on physical
– Chart 34-4 exam?
– Other?
 Who needs this  Psychosocial?
education?
Let’s do the Challenge p 637
What about interventions?

 Page 638
– Cough
enhancement?
– O2 Rx?
– Resp Monitoring?

 What’s missing
from this list?
What meds? P 639, 34-7

 CAP
– Most common type

 HAP
– What is difference?

 What about
aspiration
pneumonia?
– Types?
 Chemical
 Foreign body
 Toxic gases/smoke
Risk Assessment
More
 How to Score Risk
Risk 30 Day Mortality Risk Based on:
Level Class
Low Less than 0.5% I Algorithm

Low > Or = to 0.5 and < than 1.0% II 70 or fewer points

Low > Or = to 1.0 and < than 4.0% III 71 - 90 points

Moderate > Or = 4.0 and < than 10.0% IV 91 - 130 points

High > Or = to 10.0% V > 130 points

Using Predictor Rule -
Mortality Rate (%)
Points Risk Adults w/ NH pts. Recommendations
Class CAP w/ CAP

< 51 I 3/1,472
(0.2%)
None Outpatient Therapy
should be
considered

51-70 II 7/1,374
(0.5%)
None Especially for
classes I, and II

71-90 III 41/1,603

(2.6%)
1/21
(4.8%)
? Outpt Rx

91- IV 149/1,605
(9.3%)
6/50
(12.0%)
Hospitalize

130
> 130 V 109/438
(24.9%)
28/85
(32.9%)
Hospitalize

Fam Pract Manag. 2006; 13(4): 41-44

Treating CAP as Outpatient
can save $
 Large VA study
– 20 of 82 low-risk admissions
– Could have avoided hospitalization if predictor
rule had been used (PSI)
 Timely & appropriate ATB
– = better outcomes (duh)
– Study involved 14K elderly pts at 3.5K
hospitals
 CAP, > 60 yrs RX with erythromycin
– Similar outcomes over 30 days
– 1/10 as costly ($7.50 vs $73.50)
Discharge stability can
reduce mortality

 Medically unstable
– Had 1 of 7 factors
– 60% > risk
 Readmission OR
 Death

 Seven Factors?
– Temp, heart rate, BP,
resp rate
– O2 level (ABG)
– Mental status
– Able to eat/drink?
Stanton (2002).
Other Preventions
 Flu Vaccine
– Better mortality rate (in-
hospital)
– Spaude (2007)
 Inhaling Pepper Oil
 Also tried Lavender Oil
and distilled H2O
– Reduces risk of aspiration
PX
 Improves swallow,
promotes brain activity,
appetite stimulus
– Ebihara (2006) (Japan)
 ED Algorithm for NH
acquired PX
– Better outcomes
– Curr Med Res Opin (2004)
ED Algorithm for NH PX

1. Discharge to NH
l Cefepime or Ceftriaxone + Macrolide
l OR Resp. Fluoroquinolone
l Admit Stable Patient
l Cefepime or Ceftazidime or Pip/Tazo
l Plus Resp. Fluoroquinolone or Macrolide
l Admit Unstable Patient
l Cefepime or Pip/Tazo
l Plus Quinolone or Aminoglycoside
l Plus Vancomycin

Curr Med Res Opin (2004)