1. Respiratory Infections and Pleural Condition First Semester 2014

2. Anatomy of the Lower Respiratory Tract

3. Aveoli Where gas exchange takes place Alveolar-capillary membrane Types of alveolar cells: I, II, III Surfactant

4. Lungs: -Pleura -Mediastinum -Lobes -Bronchi and Bronchioles -Alveoli

5. The Lobes of the Lungs and Bronchiole Tree

6. Function of the respiratory system Oxygen transportation Respiration and Ventilation Gas Exchange. O2 Transportation: O2: Diffuse from capillary membrane to the interstitial fluid to cell (used by mitochondria for cellular respiration. CO2: Diffuse from cell to the blood.

7. Respiration: The whole process of gas exchange between atmospheric air and the blood at the alveoli, and between the blood cells and the cells of the body. Exchange of gases occurs because of differences in partial pressures. Oxygen diffuses from the air into the blood at the alveoli to be transported to the cells of the body. Carbon dioxide diffuses from the blood into the air at the alveoli to be removed from the body.

8. Ventilation: The movement of air in and out of the airways. The thoracic cavity is an airtight chamber. The floor of this chamber is the diaphragm. Inspiration: contraction of the diaphragm (diaphragm moves downward) and contraction of the external intercostals muscles increases the space in this chamber. Lowered intrathoracic pressure causes air to enter through the airways and inflate the lungs.

9. Expiration: with relaxation, the diaphragm moves up and intrathoracic pressure increases. This increased pressure pushes air out of the lungs. Expiration requires the elastic recoil of the lungs. Inspiration normally is 1/3 of the respiratory cycle and expiration is 2/3. Air must reach the alveoli to be available for gas exchange. Perfusion is the filling of the pulmonary capillaries with blood

10. Gas Exchange:

11. Ventilation Perfusion (V/Q Ratio) Ventilation is the movement of air in and out of the lungs. Air must reach the alveoli to be available for gas exchange. Perfusion is the filling of the pulmonary capillaries with blood. Adequate gas exchange depends upon an adequate V/Q ratio, a match of ventilation and perfusion. Shunting occurs when there is an imbalance of ventilation and perfusion. This results in hypoxia

12. Ventilation-Perfusion Ratios: A- Normal Ratio: Given amount of blood passes an alveolus is matched with equal amount of gas (1:1 ratio) V match P( Q) B- Shunts (low VP ratio): perfusion exceed ventilation, in obstruction of the distal airway as in pneumonia, atelectasis, tumor, mucus plug. C- Dead Space ( high VP ratio): ventilation exceed perfusion, seen in blockage in circulation as in pulmonary emboli or infarction & cardiogenic shock D- Silent Unit: occur in absence or limited ventilation and perfusion, seen in pneumothorax and sever acute RDS

13. A- Normal RatioC- Dead Space B- Shunts D- Silent Unit

14. Diagnostic Tests Pulmonary function tests Arterial blood gases Sputum tests Chest x-ray Computed tomography (CT) Magnetic resonance imaging (MRI) Fluoroscopic studies and angiography Radioisotope procedures (lung scans): V/Q scan Endoscopic Procedures : Bronchoscopy & Thoracoscopy Thoracentesis : aspiration of air or fluid from plural space Biopsies

15. Lung Volumes & Capacities Tidal volume (TV): air volume of each breathe. Inspiratory reserve volume (IRV): maximum volume that can be inhaled after a normal inhalation. Expiratory reserve volume (ERV): maximum volume that exhaled after a normal exhalation. Vital capacity (VC): the maximum volume of air exhaled from a maximal inspiration, VC = TV + IRV + ERV. Forced vital capacity (FVC): VC performed with a maximally force expiratory effort. Forced expiratory volume (FEV): volume exhaled forcefully over time in seconds. Time is indicated as a subscript, usually 1 second. Tables (23-1) & (23-8)

16. Measurement of Volume and Inspiratory Force Pulmonary function tests assess respiratory function & determine the extent of dysfunction. A spirometer measures volumes of air exhaled and is used to assess lung capacities. When assessing TV, measure several breaths. TV varies from breath to breath. Peak flow rate reflects maximal expiratory flow and is frequently done by pts using a home spirometer.

17. Inspiratory Force Evaluates the effort of the patient in making an inspiration. A monometer which measures inspiratory effort can be attached to a mask or endotracheal tube to occlude (10-20 sec) the airway and measure pressure. Normal inspiratory pressure is approximately 100 cm H2O. Force of less than 25 cm H2O usually requires mechanical ventilation.

18. Arterial Blood Gases Measurement of arterial oxygenation and carbon dioxide levels. Used to assess the adequacy of alveolar ventilation and the ability of the lungs to provide oxygen and remove carbon dioxide. Also assesses acid base balance

19. Pulse Oximetry A noninvasive method to monitor the oxygen saturation of the blood. Does not replace ABGs Normal level of SpO2 is 95-100%. May be unreliable: in cardiac arrest, states of low perfusion, anemia, high Co2, dark skin, use of dyes, nail polish, bright light, movement (shivering), vasoconstrictor medications, o2 therapy.

20. Pulse Oximeter

21. Fiberoptic Bronchoscopy and Rigid Bronchoscopy

22. Endoscopic Thoracoscopy

24. Major Sign and Symptoms of respiratory Disease Dyspnea (SOB): associated with Tachypnea & orthopnea Cough: Sputum production Chest pain Wheezing Clubbing of the finger Hemoptysis Cyanosis

25. Respiratory Infections Acute Tracheabronchitis Pneumonia

27. Acute Tracheabronchitis -Acute inflammation of the mucous membrane of the trachea and bronchial tree. -Causes: Infection (URTI), inhalation of physical and chemical irritant, gases. -Pathophysiology: inflamed mucosa from (SP, HI, MP) or fungal agent produce mucopurelant sputum -C\M: initially the pt c\o -dry irritating cough, -scanty amount of mucoid sputum, -retrosternal soreness may occur, -fever and chills, headache, general malaise.

29. Acute Tracheobronchitis

30. -C\M: as infection progress: S.O.B, noisy inspiration and expiration, purulent (puss filled) sputum occur. -Dx evaluation: sputum culture and sensitivity C&S *Medical Management: -AB (antibiotics), -expectorant, -increase fluid intake, -steam inhalation, -moist heat to the chest, -analgesic & antipyretic *Nursing Management: -Increase fluid intake, -coughing exercise, -place pt in setting position, -instruct pt to complete the course of AB treatment, -avoid overexertion & instruct pt to rest.

31. Pneumonia Is an inflammation of the lung parenchyma, caused by various microorganisms Classification: common classifications: Community Acquired Pneumonia (CAP), Hospital Acquired Pneumonia (HAP), pneumonia in immunocompromised host, Aspiration Pneumonia. Others: Bacterial or typical, atypical, anaerobic, opportunistic, CAP: -Occurs in the community setting or within the first 48hr’s after hospitalization -The causative agents: S.pneumoniae, H.influanzae, legionella, pseudomonas areuginosa -The most common CAP the S.pneumoniae (pnemococcus), occur in people younger than 60y without comorbidity and ≥ 60y with comorbidity

32. -Mycoplasma pneumonia another type of CAP, caused by Mycoplasma pneumonia, occur in olds, children, and young adults -H.influanzae another cause of CAP, affects elderly with comorbid illness (DM) HAP: - Known as nosocomial pneumonia -Onset of pneumonia symptoms >48hr’s after admission in pt with no evidence of infection at the time of admission -Organism responsible as: Enterobacter species (EC), Klebseilla species, Staphylococcus.aureus, S.pneumoniae.

33. Pneumonia in the immunocompromised host: -Include Pneumocystis Carinii Pneumonia (PCP), fungal pneumonia, mycobacterium tuberculosis. -The organism that causes CPC now known as Pneumocystis jiroveci Pneumonia -Occur with use of corticosteroid, chemotherapy, AIDs, and other factor that cause CAP and HAP Aspiration Pneumonia: -Refer to the pulmonary consequences resulting from entry of endogenous or exogenous substances into the lower airway ….(most commonly: bacteria reside normally in URT) -Common pathogens: S. pneumonia, H.influanzae, S.aureus -Other causes aspiration of gastric content, irritating gases.

34. Pathophysiology Affect both ventilation and perfusion (V/Q) Inflammatory reaction occur in the alveoli produce exudates which interfere with diffusion of O2 and CO2 Area of lungs not adequately ventilated If one or more lobes is involved this called “lobar pneumonia”, the entire lobe of lung consolidated. If one or more localized area within the bronchi and extending to the surrounding parenchyma this called “bronchopneumonia”, patchy area of consolidation occur Bronchopneumonia more common than lobar pneumonia

39. Risk Factors Cancer, smoking, COPD (produce mucus, or obstruct bronchus Immunocompromised pt Prolonged immobility and shallow breathing Depressed cough reflex, aspiration of foreign material Alcoholism GA, sedative Advance age Respiratory therapy with improperly cleaned equipment Transmission of organisms from staff of health care.

40. Clinical Manifestation Sudden onset of chills, rapid raising fever (38.5 – 40.5 o ) Pleuritic chest pain (↑with deep breathing& coughing Orthopnea & Tachypnea ( 25 – 45b\m) Rapid bounding pulse In sever cases: cheeks flushed & the lips with nail beds become cyanosed. Decrease appetite, fatigue Purulent sputum Crackles, PE: increased tactile fremitus, dullness on percussion, bronchial breathing sounds, egophony and whispered pectoriloquy.

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42. Diagnostic Finding Hx (recent respiratory tract infection) Physical examination Chest X-ray Blood culture Sputum culture

44. Medical Management Supportive treatment includes Fluids, Oxygen for hypoxia, Antipyretics, Antitussives, decongestants, and antihistamines. Antibiotic therapy (determined by Gram stain results) Antibiotics are not indicated for viral infections but are used for secondary bacterial infection

45. Collaborative Problems Shock Respiratory failure Atelectasis Pleural effusion confusion

46. Nursing Process: The Care of the Patient with Pneumonia: Assessment Changes in temperature and pulse Secretions (amount, odor, color) Cough (frequency and severity) Tachypnea and shortness of breath Changes in physical assessment, especially inspection and auscultation of the chest Changes in CXR findings Changes in mental status, fatigue, dehydration, and concomitant heart failure, especially in elderly patients

47. Nursing Process: The Care of the Patient with Pneumonia: Diagnosis Ineffective airway clearance R\T copious tracheobronchial secretions. Activity intolerance R\T impaired respiratory function. Risk for fluid volume deficit R\T fever and rapid respiratory rate Imbalanced nutrition: less than body requirements Deficient knowledge regarding treatment regimen and preventive health measure.

48. Nursing Process: The Care of the Patient with Pneumonia: Planning Improved airway clearance Maintenance of proper fluid volume Maintenance of adequate nutrition Patient understanding of treatment and prevention Absence of complications (Assessment) Promote rest and conserve energy.

49. Improving Airway Clearance Encourage hydration: 2-3 L/day, unless contraindicated Humidification may be used to loosen secretions; by face mask or with oxygen Coughing techniques Chest physiotherapy Position changes Oxygen therapy administered to patient needs

50. Other Interventions Promoting rest – Encourage rest and avoidance of overexertion. – Positioning to promote rest and breathing (semi- Fowler’s) Maintaining nutrition – Provide nutritionally enriched foods and fluids. Patient teaching

51. Pleural Condition Disorders involve the membranes cover the lung (Visceral ) and the surface of chest wall (parietal) or the space between pleura. Pleurisy Pleural Effusion Empyema

53. Pleurisy Inflammation of both layers of the pleura Developed due to: pneumonia, TB, trauma to the chest wall, PE, URTI, metastatic cancer. C\M: Pleuritic pain: (local or radiated, usually on one side; ↑with deep breath &cough). Pain ↓when hold breathing, & as pleural fluid develop Dx Finding : Pleural friction rub, CXR, Sputum examination, Thoracentesis, pleural biopsy.

55. Medical Management: -Discover the underlying condition -Monitor S&S of pleural effusion -Analgesic -NSAID’s Nursing Management: -Place pt on the affected side -Instruct pt to use hands or pillows to splint the rib cage while coughing.

56. Pleural Effusion A collection of fluid in the pleural space It is occur due to other disease (HF, TB, pneumonia, pulmonary infections (viral), nephrotic syndrome. Normal pleural fluid amount (5-15ml)

58. Pathophysiology: -Due to accumulation of clear fluid (exudative or transudative) in the pleural space -Transudate: filtrate of plasma moves across intact capillary wall, low in protein (due to Alt. in the formation or reabsorption of pleural fluid) commonly due to heart failure -Exudate: extravasations of fluid into tissue or cavity. Due to inflammation or or tumor in pleural space. -Increase fluid cause compression on lung tissue affect lung expansion.

59. C\M: Depend on the underlying cause: If due to -Pneumonia (fever, chills, pleuratic chest pain) -Malignant causes (dyspnea, difficulty lying flat, coughing) Severity of symptoms depends on the size of effusion: -Large effusion causes dyspnea, -Moderate effusion causes minimal or no dyspnea.

60. Dx finding: Decrease or absent Breathing sounds SOB Decreased fremitus on palpation Percussion (dullness) In severe effusion: Mediastinum shifts toward (unaffected side). Tracheal deviation away from affected side CXR, chest CT, Thoracentesis (confirm presence of fluid Pleural fluid analysis Pleural biopsy

61. Decubitus X Ray Normal X Ray

63. Medical Management: -Directed towered the underlying cause -Thoracentesis to remove fluid and obtain specimen -Chest tube connected to water sealed drainage system -Pleurodesis for malignant effusion Nursing Management: -Prepare pt for thoracentesis and specimen -Monitor the chest tube -Place pt on comfortable position -Pain management

64. Empyema Accumulation of thick, purulent fluid in the pleural space Fibrin development and loculated area at the place of infection Pathophysiology: Pathophysiology: -Occur as a complication of bacterial pneumonia or lung abscess, penetrating lung trauma. -First pleural fluid is thin and with low leukocyte -Then it become fibropurulent -Finally lung encloses with thick exudative membrane (loculated empyema)

65. C\M: C\M: fever, night sweat, pleural pain, cough, dyspnea, anorexia, Wt loss Dx finding: Dx finding: decrease breathing sound over the affected area, dullness, decrease fermitus, chest CT Medical management: Medical management: Objective: to drain the pleural cavity to achieve lung expansion -AB for 4-6weeks -Thoracentesis (needle aspiration) [ small volume, not too purulant fluid] -Tube thoracostomy (chest drainage) with fibrinolytic agent -Open chest drainage with rib resection: to remove thickened pleura & debris the diseased pulmonary tissue Nursing management: Nursing management: -Help pt cope with condition -Instruct pt in lung expansion exercise -Care to the method of drainage to remove pleural fluid

66. Pulmonary Edema Abnormal accumulation of fluid in the lung tissue, the alveolar space, or both Pathophysiology: Pathophysiology: -Increase microvascular pressure in pulmonary vasculature ( inadequate left ventricular function -Rapid shift of fluid from the plasma to pulmonary interstitial tissue and alveoli -Causes impaired gas exchange C\M: Respiratory distress : dyspnea, air hunger, central cyanosis. Anxiety, agitation, foam, frothy blood tinged sputum, confusion. C\M: Respiratory distress : dyspnea, air hunger, central cyanosis. Anxiety, agitation, foam, frothy blood tinged sputum, confusion.

68. Dx finding: Dx finding: -Crackles in the base of the lung (posterior base) -Tachycardia -Decrease O2 saturation -ABG’s: hypoxemia Medical Management: Medical Management: -Vasodilators, & medication enhance contractility of the heart -If fluid overload is the cause diuretic is administered with fluid restriction -O2 for hypoxemia -Morphine to decrease pain and control anxiety. -Mechanical ventilator Nursing Management: Nursing Management: -Administer O2, medication and monitor pt responses