DISORDERS OF THE UPPER AIRWAY PN 132

Learning Objectives Identify common disorders / diseases of the upper respiratory system Discuss etiology and pathophysiology associated with disorders / diseases of the upper airway Identify cardinal signs and symptoms associated with disorders / diseases of the upper airway Identify components used in the management of a client with an upper respiratory disorder or illness Discuss assessment, diagnostic, nursing interventions and management, and patient education important to clients with upper respiratory disorders

Upper Respiratory Disorders

Upper Respiratory Infections

Common Respiratory Infections Acute Rhinitis Acute Follicular Tonsillitis Laryngitis Pharyngitis Sinusitis

Acute Rhinitis (Coryza) Etiology and Pathophysiology Also known as the “common cold” Inflammation of mucous membranes in nose and sinuses Usually caused by one or more viruses Can be complicated by bacterial infection Contaminate hands when coughing or sneezing Spreads by touching things Commonly spread by shaking hands with infected person Signs and Symptoms Evident within 24 to 48 hours after exposure Increased sinus drainage Postnasal drip Throat irritation Headache Earache Fever

Acute Rhinitis (Coryza) Diagnostics and Labs Throat and sputum cultures Medical Treatment No treatment available for Coryza Treat symptoms ASA, Tylenol to reduce fever Cough suppressant for non-productive cough Expectorant for productive cough Antibiotics if bacterial

Acute Follicular Tonsillitis Etiology and Pathophysiology Inflammation of the tonsils Results from airborne or foodborne bacterial infection Commonly streptococcus Most common in school age children Signs and Symptoms Sore throat Fever Chills General muscle aching General malaise Elevated WBCs Increased throat secretions Enlarged tonsils

Acute Follicular Tonsillitis Diagnostics and Labs Throat Cultures CBC (to determine WBC count) Medical Treatment Antibiotics Elective tonsillectomy and adenoidectomy (T&A) Tonsils and adenoids are surgically excised Usually for those who have recurrent attacks Analgesics and antipyretics Warm saline gargles

Laryngitis Etiology and Pathophysiology Often occurs secondary to another respiratory infection Common disorder Acute and/or chronic Acute Laryngitis Can cause respiratory distress in young children (small larynx) Chronic Usually associated with inflammation of laryngeal mucosa or edema in vocal cords Accompanies viral or bacterial infections Other Causes Excessive use of the voice Inhalation of irritating fumes

Laryngitis Signs and Symptoms Diagnostics and Labs Medical Management Hoarseness Complete voice loss Throat feels scratchy and irritated Patient may have persistent cough Diagnostics and Labs Laryngoscopy Visualizes edema, drainage Medical Management Antibiotics (if bacterial) Analgesics or antipyretics Antitussives (to relieve cough) Throat lozenges

Pharyngitis Etiology and Pathophysiology Signs and Symptoms May be chronic or acute Most common throat inflammation Frequently accompanies the common cold Usually viral Can be caused by bacteria Streptococci Staphylococci Contagious for 2 to 3 days after the onset of signs and symptoms Signs and Symptoms Dry cough Tender tonsils Enlarged cervical lymph glands Throat looks edematous Throat soreness Severe pain to scratchy Difficulty swallowing

Pharyngitis Diagnostics and Labs Medical Management Rapid strep screen (to detect streptococci) Two throat swabs obtained so culture can be performed if strep screen test is negative Medical Management Antibiotics Analgesics and antipyretics Throat rinses and gargles Rest Vaporizer

Sinusitis Etiology and Pathophysiology Signs and Symptoms Acute or chronic Involves any sinus area Can be viral or bacterial Often complication of pneumonia or nasal polyps Begins as upper respiratory tract infection that leads to sinus infection Signs and Symptoms Complaints of constant/severe headache Pain and tenderness in the affected sinus area Purulent exudate

Sinusitis Diagnostics and Labs Medical Treatment Sinus X-ray and/or CT scan Trans-illumination Shining bright light into the mouth with the lips closed around it Infected areas of sinuses will look dark Unaffected areas will trans-illuminate Medical Treatment Nasal windows Surgical incisions that allow sinuses to drain Medication Antibiotics Analgesics Antihistamines Vasoconstrictors (nasal sprays)

Epistaxis

Epistaxis (Nose Bleed) Pathophysiology Congestion of the nasal membranes that leads to rupture of the capillaries Abundance of capillaries in the nasal passages Frequently caused by Injury Primary or secondary disorder Can be related to Menstrual flow Hypertension With treatment, prognosis is good

Epistaxis Etiology Bleeding can be prolonged if using Dryness Chronic infection Trauma Topical corticosteroid use Nasal spray abuse Street drug use (cocaine) Disorder that results in decreased platelet count Bleeding can be prolonged if using Aspirin NSAIDS

Epistaxis Clinical Manifestations Bright, red blood Severe hemorrhage One or both nostrils Severe hemorrhage Up to 1 liter of blood loss / hour Can result in EXSANGUINATION (rare) Fatal blood loss Hypovolemic shock (>1/5th total blood volume lost) Ex: early compensatory response of the body during early dehydration is to increase the HR (pulse) and increase the blood pressure; later dehydration (more serious) there is an increased pulse due to ↓ BP.

Epistaxis

Epistaxis Assessment Subjective Assessment Patient interview Ask about: Duration Severity of bleeding Precipitating factors Objective Assessment Assess presence of bleeding Anterior / posterior to nasal passage Blood pressure (severe drop may be indication of shock) Temperature Pulse Respirations Evidence of hypovolemic shock Hypovolemic shock: early blood loss: ↑HR↑BP↑RR ↑ ventilation; Late blood loss: ↑HR(weak pulse) ↓BP and RR↑ or ↓ In reference to : “Evidence of hypovolemic shock”: decrease or increase in breathing due to body compensating and then decompensating; My Notes: rapid shallow breathing d/t SNS and respiratory acidosis; usually can be slow, shallow breathing due to metabolic acidosis. ???

Epistaxis Medical Intervention Nasal packing Cautery Balloon Tamponade Cotton saturated with epinephrine Cautery Burning the bleeding vessel Use of silver nitrate stick (chemical) Balloon Tamponade Foley-like catheter inflated in the nose Antibiotics Reduce chance of infection

Balloon Tamponade

Epistaxis Diagnostics and Labs Blood Labs Nasal Endoscopy (HCT, PT, INR, PTT) Blood loss severity Clotting abnormalities Nasal Endoscopy Identify source of bleeding

Epistaxis Nursing Diagnoses Ineffective tissue perfusion: R/T Blood Loss Risk for Aspiration: R/T Bleeding

Epistaxis Monitor vital signs Monitor for s/s hypovolemic shock Nursing Interventions Keep patient quiet Sitting position / leaning forward Reclining with head and shoulders elevated Apply direct pressure 10 to 15 minutes Pinch lower soft portion of the nose Apply ice compresses to the nose Have patient suck on ice If bleeding continues Insert a small gauze pad into the bleeding nostril Monitor vital signs Monitor for s/s hypovolemic shock Anxiety Cool , clammy skin Confusion Decreased urine output Weakness Pale skin color Rapid breathing Moist skin / sweating unconsciousness

Epistaxis Patient Teaching Don’t pick or scratch in or around nares Don’t blow the nose vigorously Avoid dryness to the nose Use: Vaporizer Saline or nasal lubricants Avoid Aspirin and NSAIDs Sneeze with mouth open Don’t insert foreign objects into the nose

Deviated Septum and Nasal Polyps Nasal polyps—common, non CA, tear drop-shaped growths. Larger polyps can block normal drainage from the sinuses and lead to infection therefore thick, discolored drainage in nose and throat. Webmd.com (google: “What causes nasal polyps”).

Deviated Septum and Nasal Polyps Pathophysiology Deviated Septum Nasal septum deviates from the midline Partial nasal obstruction Nasal Polyps Tissue growths on nasal tissues

Deviated Septum and Nasal Polyps Etiology Deviated Septum Nasal Polyps Congenital abnormality Injury Prolonged sinus inflammation Allergies

Deviated Septum and Nasal Polyps Clinical Manifestations Blockage of nostrils / Nasal congestion Frequent nose bleeds Facial pain Headache Post nasal drip Noisy breathing during sleep (infants and children) Dyspnea (struggling / strenuous respirations) Harsh snoring sounds (Stertorous Respirations)

Deviated Septum / Nasal Polyps Assessment Subjective Ask about: Previous injuries / infections Allergies Sinus congestion Complaints of Dyspnea Post nasal drip Objective Identify condition and location Rate and character of respirations Note s/s of dyspnea

Deviated Septum / Nasal Polyps Diagnostics Visual Examination Sinus Radiographic Studies Shadowy sinuses = polyps present - Deviated Septum

Deviated Septum / Nasal Polyps Medical Management Medications Corticosteroids (Prednisone) Cause polyps to decrease/ disappear Antihistamines Reduce allergy signs/symptoms Decreases congestion Antibiotics To prevent infection Analgesics Relieve headache Surgical Correction Nasoseptoplasty (to align nasal septum) Nasal Polypectomy Surgical removal of polyps Following surgery Nasal packing (controls bleeding) Nasal irrigation (saline) Petroleum jelly to nares (prevent drying)

Deviated Septum / Nasal Polyps Nursing Diagnoses Ineffective airway clearance R/T nasal exudates Risk for injury R/T trauma to bleeding site associated with vigorous nose blowing

Deviated Septum / Nasal Polyps Nursing Interventions Maintain patent airway and prevent infection Monitor for s/s of infection Monitor for s/s hemorrhage Maintain patient comfort

Deviated Septum / Nasal Polyps Patient Teaching Avoid: vigorous nose blowing coughing holding your breath while bearing down (at least 2 days post-op) Notify Physician if bleeding infection occurs Use nasal sprays and drops sparingly Facial edema and ecchymosis may appear post-op

Antigen-Antibody Allergic Rhinitis and Allergic Conjunctivitis HAY FEVER

Hay Fever Pathophysiology Atopic allergic condition Affects Nasal membranes Nasopharynx Conjunctiva Ciliary action slows Mucosal gland secretion increases Leukocyte infiltration occurs Increased capillary permeability and vasodilation Local tissue edema results

Hay Fever (AKA allergic Rhinitis) Etiology Antigen / Antibody Reaction Inhalation or contact with allergens Common allergens Tree, Grass, Weed Pollen Mold spores Fungi House dust Mites Animal dander Foods Drugs Insect bites and stings Cold-like s/s; however cause by allergies

Hay Fever Clinical Manifestations and Assessment Chronic S/S Edema Photophobia Edema Blurred vision / watery eyes Pruritus Excessive tear production Cough / Sneezing Epistaxis Headache Congestion Excessive nasal secretions (rhinitis) Otitis media complaints of: Ear fullness and popping Decreased hearing Chronic S/S Headache Severe nasal congestion Post nasal drip Cough If untreated secondary infections may occur Otitis media Bronchitis Sinusitis pneumonia What is otitis Media? How do you get an ear infection? Photophobia (conjuctivitis) Edema (local tissue edema) HA and congestions (sinus pressure and facial pain). Pruitus=eyes, nose, ears, roof of mouth or throat itchy swollen, blue-colored skin under the eyes (allergic shiners) decreased sense of smell and taste

Hay Fever Diagnostics Physical exam of eyes and ears Skin Testing RAST test (blood test Measures allergy antibody produced when mixed with allergens

Hay Fever Medical Management Relieve symptoms Avoid allergen Antihistamines Topical or Nasal Corticosteroids Leukotriene Receptor Antagonists Decongestants Lodoxamide (conjunctivitis) Analgesics (headache) Hot Packs

Hay Fever Self-limiting illness Focus on: Nursing Interventions Self-limiting illness Focus on: Health promotion and self-care teaching Ways to avoid allergens Symptom control Medication action and usage

Upper Airway Obstruction

Upper Airway Obstruction Etiology and Pathophysiology Recent respiratory event Trauma to the airway or to the surrounding tissues Laryngeal spasm Laryngeal edema Common items that obstruct the upper airway are: Choking on food Dentures Aspiration of vomitus or secretions The tongue (the most common in an unconscious person)

Upper Airway Obstruction Clinical Manifestations Main Signs Stertorous or Stridor Respirations Altered respiratory rate and character Apneic periods

Upper Airway Obstruction Assessment Subjective Limited Difficult time with breathing Difficulty speaking Objective Signs of hypoxia Disorientation, fatigue, anxiety Cyanosis of the skin, lips, and nail beds Snoring, wheezing, or stridorous respirations Bradycardia Shallow, slow respirations (bradypnea) # 4 occurs as the amount of time is prolonged and the respiratory centers in the medulla oblongata and pons are depressed.

Upper Airway Obstruction Diagnostics Medical emergency No diagnostic tests Prompt, accurate assessment and treatment

Upper Airway Obstruction Medical Management Abdominal Thrusts To remove obstruction Maintain patent airway Artificial Airway Endotracheal Pharyngeal Tracheal Emergency Tracheostomy (Video) http://www.youtube.com/watch?v=d_5eKkwnIRs

Upper Airway Obstruction Nursing Diagnoses Ineffective airway clearance R/T obstruction in airway Risk for aspiration R/T partial airway obstruction. AHN pg. 417

Upper Airway Obstruction Nursing Interventions Emergent Open the airway and restore patency Remove foreign body Abdominal Thrusts (Heimlich) Reposition the head and neck Head-tilt/chin lift technique Do this like you learned in CPR

Upper Airway Obstruction Patient Teaching Prevention!!!!!! Educate about Heimlich Maneuver Recommend a CPR class Discourage talking while eating Encourage eating slowly and chewing food thoroughly

Summary Identified common disorders / diseases of the upper respiratory system Discussed etiology and pathophysiology associated with disorders / diseases of the upper airway Identified cardinal signs and symptoms associated with disorders / diseases of the upper airway Identified components used in the management of a client with an upper respiratory disorder or illness Discussed assessment, diagnostic, nursing interventions and management, and patient education important to clients with upper respiratory disorders

Assignment Read and Review Begin research for Mid-Term Paper Due Day 6 AHN – Chapter 9 (Pp. 384-390) PowerPoint Handout Begin research for Mid-Term Paper Due Day 6 Topic will be assigned for paper and group presentation

Next Class Disorders of the Lower Airway AHN – Chapter 9 (Pp. 395 – 420)

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