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Care of the Chronic Respiratory Client Keith Rischer RN, MA, CEN 1 Todays Objectives Compare & contrast pathophysiology and clinical manifestations of asthma, emphysema, bronchitis & lung cancer. Identify the diagnostic tests, nursing priorities, and client education with asthma, emphysema, bronchitis, & lung cancer. Describe the mechanism of action, side effects and nursing responsibilities with pharmacologic management of asthma, emphysema & bronchitis. Contrast and compare medical vs. surgical management for treatment of lung cancer. Identify nursing priorities and care of the client with a chest tube. Identify nursing priorities and care of the client on a mechanical ventilator. 2 Obstructive Airway Disorders Increase resistance to airflow Bronchi smooth muscle innervated by autonomic nervous system • • • Parasympathetic stimulation Sympathetic stimulation Inflammatory mediator response COPD • Chronic-recurrent obstruction Emphysema bronchitis 3 Obstructive Disorders:Asthma Patho • Intermittent & reversible airway obstruction INFLAMMATION-Chronic – Antibody molecules (IgE) – Mast cells>histamine>WBC – Physiological response to inflammation » Vessel dilation>capillary leakage>tissue swelling>incr. secretions Airway hyper-responsiveness Childhood – Allergens – smoking – Cold/dry air – Bacteria Bronchospasm – edema & mucous 4 What is a Mast Cell? Bag of Granules Located in connective tissue • close to blood vessels Histamine released • Increase blood flow • Increase vascular permeability • Binds to H1, H2 receptors 5 Etiology of asthma Intrinsic etiologies • uncertain causes • physical or psychological stress • exercise-induced Extrinsic etiologies • antigen-antibody (allergic) reaction to specific irritants air pollutants sinusitis cold and dry air Meds-ASA food additives hormonal influences GE reflux 6 Clinical manifestations of Asthma Severe dyspnea • • wheezing with expiration or inspiration Which is worse… Tachypnea Cough Feelings of chest tightness Prolonged expiration Diminished breath sounds Increased heart rate and blood pressure Restlessness, anxiety, agitation 7 Asthma: Lab & Dx Findings Decreased pO2 Decreased pCO2 • • • Forced vital capacity (FVC) Peak flow meter ABG’s • • Early Late findings Elevated eosinophil count CXR Pulmonary Function Test • • • • pH 7.28 pO2-55 pCO2-60 HCO3-22 O2 sats-86% RA ABG’s • • • • • pH 7.35 pO2-75 pCO2-30 HCO3-22 O2 sats-90% RA 8 Pharmacologic Treatment Options Relievers = short-acting bronchodilators • quickly relieves bronchoconstriction and symptoms Controllers = daily medications taken on a long-term basis • • useful for controlling persistent asthma includes anti-inflammatory agents and long-acting bronchodilators 9 Beta-2 agonists chart 33-5 p.590-592 Mechanism • bronchodilation through bronchial smooth muscle relaxation mediated by beta-2 receptors in the lung Short Acting • albuterol (Proventil, Ventolin) Xopenex • Pirbuterol (Maxair autoinhaler) • Terbutaline (Brethaire) Long acting • Salmeterol-Serevent Onset: 5-15 minutes Duration: 4-6 hours 10 Beta-2 agonists Uses: • Rescue medication to relieve acute symptoms & prevention of bronchospasms prior to a precipitating event (e.g. exercise) Adverse effects: • • • • • Tachycardia Restlessness Tremors Palpitations paradoxical bronchoconstriction 11 Anticholinergics Mechanism • • block parasympathetic nervous system influence SNS dominates Ipratropium (Atrovent) Onset: 3-30 minutes, peak: 1-2 hours Duration: 4-8 hours Adverse effects • • drying of mouth and respiratory secretions increased wheezing in some individuals 12 Inhaled Corticosteroids Mechanism • • • Decrease inflammation block late reaction to allergens and reduce airway hyperresponsiveness inhibit microvascular leakage Common Meds…used qd • • • budesonide (Pulmocort) fluticasone (Flovent) triamcinolone (Azmacort) 13 Inhaled Corticosteroids (cont.) Uses: • • long-term prevention of symptoms (suppression, control, and reversal of inflammation) reduce/eliminate oral steroid use Adverse effects: • • oral candidiasis ??systemic effects at high doses 14 Oral Corticosteroids Common agents • Prednisone Uses • short term (3-10 days) “burst therapy” to gain prompt control of asthma • methylprednisolone (Medrol, Solu-Medrol) to prevent progression of exacerbation, speed recovery, and reduce relapse long-term prevention of symptoms in severe persistent asthma LT Side Effects • • • • • • HTN Peptic ulcers Skin fragility Impaired immunity Thromboembolism Cushingoid appearance 15 Asthma:Combination Inhalers Advair Diskus • • • Fluticasone Salmeterol (serevent) Frequency 1 inhalation q12 hours Combivent MDI • • • Ipratropium (atrovent) Albuterol Frequency 2 puffs 4 times daily 16 Asthma: Other Medications Leukotriene Antagonists • • • anti-inflammatory Montelukast (Singulair) Therapeutic response Decreased frequency & severity of attacks Decreased exercise induced bronchoconstriction Mast cell stabilizers • • • Mechanism Cromolyn sodium (Intal) Frequency 1-2 inhalations 4 times daily 17 Asthma:Regimen by Severity Mild • • Moderate • • Short-acting beta-agonist inhaler Anti-inflammatory inhaler used for mild symptoms occurring daily Anti-inflammatory inhaler plus medium-dose corticosteroid inhaler used for moderate symptoms occurring daily or more often Severe • • Anti-inflammatory inhaler plus long-acting bronchodilator plus oral corticosteroid used for severe symptoms occurring daily or more 18 Priority Nursing Diagnoses for Asthma Impaired gas exchange r/t… Ineffective breathing pattern r/t… Ineffective airway clearance r/t… Anxiety r/t… Deficient knowledge 19 Asthma:Critical Care Management Status asthmaticus/severe asthma Physical assessment • Dyspnea/tachypnea • Wheezing I/E • Diminished aeration to no air movement • Accessory muscles Medical management …remember A,B,C,s • O2 • Albuterol neb • Epinephrine subq • Establish IV • IV steroids (solumedrol) • Prepare for possible intubation 20 Planning and implementation for Asthma Assess respiratory and oxygenation status Administer supplemental oxygen as needed Administer broncholdilators as prescribed Observe characteristics of sputum Identify/avoid/remove precipitating factors Teach patient relaxation techniques Prepare for IV access Be prepared for intubation Diagnostic studies Emotional support for patient and family 21 Expected outcomes/evaluation Absence of dyspnea, chest tightness, wheezing Respiratory rate 12-20 breaths per minute Pulse oximetry/arterial blood gas values within normal range for client Bilaterally clear and equal breath sounds Afebrile Adequate airway clearance Absence/resolution of anxiety Clear chest x-ray or return to patient’s baseline Normal or improved peak flow 22 Asthma: Patient Education Identify asthma triggers Teach patient/family proper used of metereddose inhaler • Chart 33-6 p.593 Rescue inhalers! Instruct client regarding the use of peak flow meter for self-assessment of asthma status Asthma symptoms requiring emergency intervention 23 Emphysema: Patho Loss of lung elasticity • • Alveolar destruction Excessive enlargement Loss of “curves” impairs gas exchange Compensation… Hyperinflation of lung • • • Secondary to air trapping “barrel chest” appearance “Pink puffer O2 diffused easier than CO2 CO2 accumulates causing chronic resp. acidosis 24 Emphysema: Causes & Complications Cigarette smoking • • • Chronic respiratory inflammation • Pack years required Smoke>enzyme elastase protease>destroys alveoli Destroys cilia air pollution Complications • • • • Hypoxemia & acidosis Resp. infections/pneumonia Cur pulmonale Cardiac dysrhythmias 25 Emphysema: PhysicalAssessment…A,B,C’s General appearance • • Emaciated Barrel chest Airway/breathing • • • • • Dyspnea Tachypnea Accessory muscle use Pursed lip breathing Lung sounds • • overall diminished, and wheezes or crackles may be present Dry cough more so than productive O2 sats… Circulation • • tachycardia (inadequate oxygenation) Arrythmias 26 Emphysema: Diagnostic Tests ABGs • Chronic resp. acidosis • • • Compensation w/HCO3 • Assess pO2, pCO2 and HCO3 • • • WBC Hgb Hct polycythemia Chest x-ray • ABG’s • CBC • hyperinflated lungs with a flattened diaphragm pH 7.35 pO2-55 pCO2-60 HCO3-22 O2 sats-86% RA ABG’s • • • • • pH 7.35 pO2-55 pCO2-60 HCO3-35 O2 sats-86% RA 27 Chronic Bronchitis A disorder of chronic airway inflammation Major & small bronchioles • • Chronic productive cough lasting at least 3 months during 2 years Chronic exposure to irritants • smoking An inflammatory response in the small & large airways resulting in… Vasodilation Congestion mucosal edema broncospasm 28 Chronic Bronchitis: Patho Etiology • Smoking Chronic inflammation • Increase in # and size of mucous glands More mucous • bronchial walls thicken/edema airflow is impeded • Smaller airways are blocked Airflow and gas exchange impacted pO2… pCO2… • Cilia disappear, and the airway clearance function is lost • Unlike emphysema, cannot increase breathing efforts to maintain blood gases • “blue bloater” • Polycythemia 29 Chronic Bronchitis: Clinical Manifestations Productive cough • • Primarily occurring during winter season foul-smelling sputum Dyspnea and activity intolerance Frequent pulmonary infections “Blue bloater” • bluish-red skin discoloration from cyanosis and polycythemia Barrel chest 30 Emphysema/Bronchitis:Medical Management Goals • • improve ventilation promote patent airway by removal of secretions Remove environmental pollutants O2 and neb therapy Chest physiotherapy Mechanical ventilation Surgical procedure • • • bullectomy lung volume reduction lung transplantation 31 Emphysema/Bronchitis: Medications Beta-adrenergic agonists • Anticholinergics • • may be beneficial for pts. w/asthma history Immunizations • may be beneficial to strengthen diaphragm contractility and decrease work of breathing Corticosteroids • Atrovent administered as maintenance by inhaler most effective bronchodilators for COPD Theophylline • bronchodilators in COPD by nebs or MDI flu and pneumonia Abx 32 Emphysema/Bronchitis: Priority Nursing Dx p.600-606 Impaired gas exchange r/t… Ineffective breathing pattern r/t… Ineffective airway clearance r/t… Imbalanced nutrition r/t… Anxiety r/t… Activity intolerance r/t… Fatigue r/t… Deficient knowledge 33 Emphysema/Bronchitis: Nursing Care Priorities remember A,B,C’s… Administer low-flow O2 as needed Position patients to maintain effective breathing Closely monitor & assess resp. status • • • Provide education and referrals for pts. w/risk behaviors • Auscultation O2 sats Response to acute interventions/O2 Referral to smoking cessation Pulmonary conditioning program Develop appropriate nutritional plans Energy conservation Exercise conditioning Assess understanding to education 34 Emphysema/Bronchitis: Patient Education Smoking cessation Teach clients how to avoid occupational or environmental pollutants Pursed lip breathing Maintain adequate nutrition with emphasis on higher calorie intake Nutrition may be optimal with frequent small meals, and 1000-2000cc of fluid daily Teach energy conservation techniques 35 Emphysema/Bronchitis: Expected Outcomes Activity tolerance is optimized Pulmonary irritants such as smoking, air pollution, or occupational exposure are avoided Pulmonary infections are reduced in number and severity Nutritional intake is adequate but not excessive for individual energy needs 36 Pulmonary Tuberculosis Patho • • • Mycobacterium tuberculosis (bacillus) Most common bacterial infection globally Aerosolized Susceptible host • • • Nonspecific pneumonitis alveoli or bronchus 5-15% ultimately develop Cell mediated immunity 210 weeks later w/+ mantoux 37 Pulmonary Tuberculosis: Infection Inflammation in lungs surrounded by lymphocytes, collagen Caseation necrosis • Necrotic tissue turned into granular mass that become calcified Seen in low to middle lobes Can spread systemically to brain, liver , kidneys, bone marrow 38 Incidence HIV Immigrant populations Crowded areas • LTC, prison, Elderly Homeless Poverty 39 Physical Assessment/Diagnosis Fatigue, lethargy, nausea, weight loss Fever…night sweats Persistent cough…productive streaked w/blood Decreased aeration, crackles Diagnosis • • • Positive smear acid-fast bacillus + sputum culture…takes 1-3 weeks to confirm Mantoux 5-10mm induration 40 Treatment Combination • • chart 34-7 p.643 Isoniazid (INH) Rifampin Pt. education • • • • Compliance! 6 months treatment required Sputum specimens q2-4 weeks during therapy No longer contagious after 2-3 weeks of treatment Once negative x3 cured 41 Nursing Priorities Airborne precautions Ventilated room N-95 mask or PAPR for any staff entering room TB drugs can cause nausea-anticipate Nutrition 42 Lung Cancer: Patho Bronchial epithelium • • 90% primary Obstruction Histologic cell type • Small cell vs. non small cell • Adenocarcinoma Small cell 20% of all lung CA 99% correlation w/smoking 35% of all lung CA Spread between smokers and non smokers Metastasis • Circulatory & lymphatic 43 Lung Cancer: Clinical Manifestations Non-specific & occur late • Bronchitis/pneumonitis secondary to obstruction • • • Depend on type & location of tumor Chills Fever Cough Bloody sputum Dyspnea • • Use of accessory muscles Wheezing-diminished aeration 44 Lung Cancer: Diagnostic CXR CT Bronchoscopy • Bronchial washing Needle/surgical biopsy 45 Lung Cancer:Medical Management Non-surgical • Chemotherapy • N&V Mucositis Alopecia Immunosuppression Pan cytopenia Radiation Best results when used w/surgery or chemo Daily for 5-6 weeks Esophagitis…esophagus proximal to lungs Side effects – – – – Skin irritation & peeling Fatigue Nausea Taste changes 46 Lung Cancer:Medical Management Surgical • Thoracotomy • Lobectomy • Tumor removal Removal lobe of lung Pneumonectomy Entire lung 47 Lung Cancer: Thoracotomy-Postop Chest tube • • Drain placed in pleural space to restore intrapleural pressure Chest tube banded & connected to Pleurovac collection chamber w/several feet tubing Drainage system • First chamber • Second chamber • Drainage from client Water seal Third chamber suction 48 Chest Tube: Nursing Priorities Assess resp. status closely Check water seal for bubbling Milk NOT strip every 2 hours Assess color-amount drainage • Call MD if >100cc/hr x2 hours first 24 hours Sterile guaze/occlusive dressing at bedside 49 Mechanical Ventilation The use of an ET and POSITIVE pressure to deliver O2 at preset tidal volume Modes • Assist Control (AC) • Synchronized Intermittent Mandatory Ventilation (SIMV) • • TV & rate preset Additional resp. receive preset TV Additional resp. receive own TV Used for weaning Continuous Positive Airway Pressure (CPAP) Bi-pap Non-mechanical receive both insp. & exp. Pressures w/facemask 50 Mechanical Ventilation Terminology • • Rate Tidal volume • Fraction of inspired O2 concentration (FiO2) • • Use lowest possible to maintain O2 sats Positive End Expiratory Pressure (PEEP) Minute volume 10-15cc/kg RR x TV AC12-TV 600-50%-+5 51 Mechanical Ventilation: Adverse Effects Complications • • • • • • Aspiration Infection-VAP Stress ulcer of GI tract Tracheal damage Ventilator dependancy Decreased cardiac output • Positive pressure decr. venous return & CO Barotrauma pneumothorax 52 Mechanical Ventilation:Nursing Priorities Monitor VS-breath sounds closely Assess ET securement/length at lip Clearance of secretions • • • Sedation • Closed suction-maintains sterility Do not do routinely Pre-oxygenate Propofol Oral care Nutritional support 53 Mechanical Ventilation:Nursing Priorities Ventilator Alarm Troubleshooting • High pressure Secretions-needs sx Tubing obstructed or kinked Biting ET • Low pressure Disconnection of tubing Follow tubing from ET to ventilator 54 Oxygen Delivery Atmospheric room air %.......??? Nasal cannula • Add 3% for each liter of flow to FiO2 • 1-6 liters Oxymizer • Reservoir to increase FiO2 per liter delivery • 6-12 liters Face mask • 40-50% FiO2 • 8-15 liters Face mask w/non-rebreather • 90-100% FiO2 55