1. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Ignatavicius Chapter 32 Care of Patients with Noninfectious Lower Respiratory Problems Block 2 Concepts: 1. Asthma 2. COPD 3. Lung Cancer 4. Pleural Effusion (lecture discussion)

2. 2 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Impact of Asthma on Health Care (U.S)  5000 ED visits each day; 217,000 ED visits each year  1000 hospital admissions every day; 500,000 hospitalizations each year  10.5 million physician office visits each year  Asthma increases odds of health care use in obese people by 33%

3. 3 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Prevalence of Asthma  Estimated 20 million (8.4%) Americans affected  Estimated 300 million people affected worldwide  More common in adult women than men  Slightly more prevalent among African- Americans than Caucasians  Number of people with asthma continues to grow

4. 4 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Asthma  Condition that occurs intermittently  Occurs in two ways:  Inflammation  Airway hyperresponsiveness leading to bronchoconstriction

5. 5 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Pathophysiology of Asthma  Intermittent and reversible airflow obstruction affecting airways only, not alveoli  Airway obstruction:  Inflammation  Airway hyper-responsiveness

6. 6 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Pathophysiology of Asthma (cont’d)

7. 7 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Etiology  Different types based on how attacks are triggered  Caused by specific allergens, general irritants, microorganisms, aspirin  Hyper-responsiveness caused by exercise, URI, unknown reasons

8. 8 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Collaborative Management  Assessment  History  Physical assessment/clinical manifestations Audible wheeze, increased respiratory rate Increased cough Use of accessory muscles “Barrel chest” from air trapping –more common in COPD Long breathing cycle Cyanosis Hypoxemia

9. 9 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Laboratory Assessment  ABGs  Arterial O 2 may decrease in acute asthma attack  Arterial CO 2 may decrease early in attack and increase later (indicating poor gas exchange)

10. 10 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Laboratory Assessment  Allergic asthma with elevated serum eosinophil count, immunoglobulin E levels  Sputum with eosinophils, mucous plugs, with shed epithelial cells

11. 11 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Pulmonary Function Tests  Most accurate with use of spirometry  Forced vital capacity (FVC)  Forced expiratory volume in first second (FEV 1 )  Peak expiratory flow rate (PEFR)

12. 12 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Interventions  Teaching for self-management  Use of peak flowmeter twice daily  Personal drug therapy plan

13. 13 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Drug Therapy  Based on step category for severity and treatment  Preventive therapy (controller drugs)  Change airway responsiveness to prevent asthma attacks  Used every day, regardless of symptoms  Rescue drugs  Actually stop attack once it has started

14. 14 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Drug Therapy (cont’d)  Bronchodilators  Short- and long-acting beta 2 agonists  Cholinergic antagonists  Methylxanthines  Anti-inflammatory agents  Corticosteroids  NSAIDs  Leukotriene antagonists  Immunomodulators

15. 15 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Other Treatments for Asthma  Exercise and activity to promote ventilation and perfusion  Oxygen therapy via mask, nasal cannula, ET tube (acute asthma attack)

16. 16 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Status Asthmaticus  Severe, life-threatening, acute episode of airway obstruction  Intensifies once it begins, often does not respond to common therapy  Patient can develop pneumothorax and cardiac/respiratory arrest  Treatment—IV fluids, potent systemic bronchodilator, steroids, epinephrine, oxygen

17. 17 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Chronic Obstructive Pulmonary Disease (COPD)

18. 18 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Chronic Obstructive Pulmonary Disease (COPD)  Includes:  Emphysema  Chronic bronchitis  Characterized by bronchospasm and dyspnea  Tissue damage not reversible; increases in severity, eventually leads to respiratory failure

19. 19 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Emphysema  Loss of lung elasticity and hyperinflation of lung  Dyspnea; need for increased respiratory rate  Air trapping caused by loss of elastic recoil in alveolar walls, overstretching and enlargement of alveoli into bullae, collapse of small airways (bronchioles)

20. 20 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Interaction of Chronic Bronchitis and Emphysema in COPD

21. 21 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Chronic Bronchitis  Inflammation of bronchi and bronchioles caused by chronic exposure to irritants, especially cigarette smoke  Inflammation, vasodilation, congestion, mucosal edema, bronchospasm  Affects only airways, not alveoli  Production of large amounts of thick mucus

22. 22 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Complications  Hypoxemia/tissue anoxia  Acidosis  Respiratory infections  Cardiac failure, especially cor pulmonale  Cardiac dysrhythmias

23. 23 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Physical Assessment & Clinical Manifestations  History  General appearance  Respiratory changes  Cardiac changes

24. 24 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Dyspnea Assessment Tool

25. 25 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Basic Laboratory Assessment  ABG values for abnormal oxygenation, ventilation, acid-base status  Sputum samples  CBC  Hemoglobin and hematocrit  Chest x-ray  Pulmonary function test

26. 26 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Interventions  Improve oxygenation and reduce carbon dioxide retention  Prevent weight loss  Minimize anxiety  Improve activity tolerance  Prevent respiratory infection

27. 27 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Drug Therapy  Beta-adrenergic agents  Cholinergic antagonists  Methylxanthines  Corticosteroids  NSAIDs  Mucolytics

28. 28 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Surgical Management  Lung reduction surgery  Preoperative care and testing  Operative procedure by median sternotomy or VATS  Postoperative care and close monitoring for complications

29. 29 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Dyspnea Management  Dyspnea during mealtime can be reduced by resting before meals  4 to 6 small meals a day

30. 30 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. COPD Community-Based Care  Home care management  Long-term use of oxygen  Pulmonary rehabilitation program  Teaching for self-management  Drug therapy  Manifestations of infection  Breathing techniques  Relaxation therapy