How the Lungs Work
The thoracic cavity is an airtight chamber. The floor of this chamber is the diaphragm.
Inspiration: contraction of the diaphragm (movement of this chamber floor downward) and contraction of the external intercostal muscles increases the space in this chamber.
Lowered intrathoracic pressure causes air to enter through the airways and inflate the lungs.
Inspiration normally is 1/3 of the respiratory cycle and expiration is 2/3.
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.
The air travels down the trachea into the lungs through the bronchi
Like branches of a tree, into smaller tubes (bronchioles) that end in clusters of air sacs (alveoli)
The O2 passes through the membranes of the alveoli into blood vessels and enters the bloodstream
At the same time, CO2 is passed through the membrane to be exhaled
Chronic Obstructive Pulmonary Disease (COPD)
Persistent obstruction of the airways occurring with chronic bronchitis , emphysema or both disorders
A chronic inflammatory lung disease that causes obstructed airflow and is not fully reversible
COPD is currently the third leading cause of death and the twelfth leading cause of disability.
Asthma is now considered a separate disorder but can coexist with COPD.
Treatable but not curable
S/S don’t typically appear until a lot of damage has already occurred
Gets worse with time
Includes diseases that cause airflow obstruction:
- Chronic Bronchitis – Inflammation of the lining of the bronchial tubes, causing increased mucous and coughing
- Emphysema – alveoli at the end of the bronchioles are destroyed
Risk factors include environmental exposures and host factors. Smoking!
More common in men but women are catching up
Primary symptoms are cough, wheezing, sputum production and dyspnea
All S/S: wheezing, coughing, sputum of various colors (clear-green). Green is not good! Means infection. Blue fingernails. Get colds easily. Once emphysema hits in, they struggle to breath so they end up losing weight because they are using so much energy to breathe.
Etiology:
- ***Smoking causes 80-90% of COPD cases. Passive smoking. Smoking increases your mucous, because you have thick mucous the ciliary is decreased because the mucous ties it down. Secondary. Tertiary: like washing clothes around smoke
- Occupational exposure (chemicals/dust)
- Ambient air pollution
- Infection- pneumonia frequently
- ***Genetic abnormalities: Alpha1-antitrypsin deficiency
- Age- 35-40 before symptoms but probably already have a problem
Pathophysiology:
- Airflow limitation is progressive and is associated with abnormal inflammatory response of the lungs to noxious agents.
- Inflammatory response occurs throughout the airways, lung parenchyma, and pulmonary vasculature.
- Scar tissue and narrowing occur in airways.
- Substances activated by chronic inflammation damage the parenchyma.
- ***Inflammatory response causes changes in: pulmonary vasculature. Definitely changes the walls
Your lungs rely on the natural elasticity of the bronchial tubes and alveoli to force air out of you body. COPD causes them to lose the elasticity and over expand, which leaves some air trapped in the lungs when you exhale, damaging the alveoli
- Airflow limitation during forced exhalation due to loss of elastic recoil
- Airflow obstruction due to mucous hyper-secretion, mucosal edema, & bronchospasms
Emphysema: barrel like chest (pink puffer)
Blue bloater: chronic bronchitis, smoker
COPD (smokers especially)- clubbing (rounded fingers)
PCs: heart problem, lung cancer, high bp, depression
Pneumonia, colds, respiratory infections faster
Steroids: glucose, taper down, osteoporosis, infections
Diagnostic tests and Treatments for COPD
Diagnostic tests:
- Pulmonary function tests
- Sputum tests: check for pneumonia, TB
- Chest x-ray
- Computed tomography (CT)
- Magnetic resonance imaging (MRI)
- Fluoroscopic studies and angiography
- Radioisotope procedures (lung scans)
- Bronchoscopy: looks in the lungs with a scope. Before they numb the throat. Cannot eat or drink after until the gag reflex comes back. Will probably aspirate if they try to eat or drink.
- **Arterial blood gases: How adequate is the alveoli working in the exchange process? 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. Taken from the arteries. **After the draw, must put pressure on the site for at least 5 minutes. pH: 7.35-7.45. ***Look for respiratory acidosis: under 7.35 (they are on oxygen over a long period of time. Usually put them on 2L/Min. Would lose drive to breath if you continue to give a high amount. Want to keep the amount as low as possible for as long as possible.)
Treatments:
Prevent STOP smoking- can arrest the progression of the disease. Smoking increases mucous. Avoid irritants Get yearly flu shots Pneumonia shot q 5 years
Therapies
Oxygen- usually 2L/Min- lowest level possible because if we give too much they lose their drive to breathe
- If the patient needs a high percentage, put them on a non-rebreather. Most COPDers are just on nasal cannula
Pulmonary rehab- exercises to work lungs to get over activity intolerance
Small meals, high calorie because they are using a lot of energy just to breathe
Meds
- Bronchodilators
- Inhaled steroids- remember to tell the patient to rinse their mouth to avoid candida/thrush
- Combination inhalers: bronchodilator and steroid combo
Oral steroids
- Phosphodiesterase 4 inhibitors: takes down inflammation. Can cause diarrhea and weight loss
- Theophylline: trimmer, tachycardia, headache, nausea
- Antibiotics: zithromax currently being used
- Meds used to control or prevent acidosis
- ***Check glucose for patients on steroids
Other Therapies:
- Pulmonary toilet
- High frequency compression device
- Nebulizers
- Acapella airway
- Flutter device
Surgical Management:
Bullectomy: Emphysema: destroyed alveoli but air is still going into the area, so the alveoli expands with air and the air won’t come out. Called a Bulli, so a bullectomy removes the expanded alveoli
Lung Volume Reduction Surgery: gets rid of lung tissue that isn’t functioning
Lung Transplantation
Pulmonary toilet
Put patient in trendelenberg
Give vasodilator
Ask the patient to take a deep breath in
Hit the patient with cupped hands on lung section of the back
Moves mucous and stuff forward so that they can get rid of it
Collaborative Problems for COPD
Exacerbations Respiratory insufficiency or failure Atelectasis Pulmonary infection Pneumonia: green mucous Pneumothorax Pulmonary hypertension
Patient teaching for COPD
Disease process
Medications: SE
Procedures: PFTs, MRI
When and how to seek help
Prevention of infections
Avoidance of irritants; indoor and outdoor pollution and occupational exposure, avoid temperature extremes
Lifestyle changes, including cessation of smoking
**Stay hydrated: thins the mucous
**Avoid sulfites (processed meats, salad bars), nitrates (bacon, bologna), gassy foods (make them burp and when they burp they could aspirate), salt, fried foods, dairy, alcohol, carbonation
Chronic Bronchitis (Blue Bloater)
S/S:
- Color Dusky to Cyanotic
- ***Recurrent cough and increased (copious amounts of thick) sputum production
- Hypoxia
- Respiratory Acidosis
- Increased Hbg
- Increased RR
- ***Dyspnea, first on exertion, later even at rest
- ***Increased incidence in heavy cigarette smokers
- ***Digital clubbing
- ***Coars Rhonchi (sounds more like snoring) and wheezing
- Cardiac enlargement
- Use of accessory muscles to breathe
- Leads to right-sided heart failure
- ***Cyanosis- fingertips, nose, anything not absolutely necessary may turn blue
- ***Always sit up first then give oxygen. Anyone with a hard time breathing, need to sit up
Chronic Bronchitis:
- The presence of a cough and sputum production for at least 3 months in each of 2 consecutive years
- Irritation of airways results in inflammation and hypersecretion of mucus.
- Mucus-secreting glands and goblet cells increase in number, causing inflammation
- Ciliary function is reduced, bronchial walls thicken, bronchial airways narrow, and mucus may plug airways. - Makes it harder to expel mucous.
- Alveoli become damaged and fibrosed, and alveolar macrophage function diminishes.
- The patient is more susceptible to respiratory infections.
- Teach diaphragmatic teachings
- More respiratory infections because the mucous is an attraction for germs
Emphysema (Pink Puffer)
S/S:
- Increased CO2 retention (pink)
- Minimal cyanosis
- Purse lip breathing
- Dyspnea
- Hyper-resonance on chest percussion
- Orthopneic
- Barrel Chest
- Exertional Dyspnea
- Prolonged Expiratory time- have to use muscles to get it out
- Speaks in short, jerky sentences
- Anxious
- Use of Accessory muscles to breathe
- Thin appearance
- ***Always sit up first then give oxygen. Anyone with a hard time breathing, need to sit up
- Minimal cough- don’t have mucous
- Increase anterior-posterior chest diameter (barrel chest)
- Tachypnea
- anorexia, weight loss
Emphysema:
- Abnormal distention of air spaces beyond the terminal bronchioles with destruction of the walls of the alveoli
- Decreased alveolar surface area causes an increase in “dead space” and impaired oxygen diffusion.
- Reduction of the pulmonary capillary bed increases pulmonary vascular resistance and pulmonary artery pressures.
- Air trapping because of loss of elasticity
- Leads to right sided heart failure
- Could lead to pulmonary hypertension
- Loss of elastic recoil decreases expiration and leads to air trapping
- Hypoxemia is the result of these pathologic changes.
- Increased pulmonary artery pressure may cause right-sided heart failure (cor pulmonale).
Pneumonia
- The collapse/airless condition of the alveoli
- Postop patients are high risk
- Symptoms- cough, sputum production, low-grade fever.
- If Area large- Respiratory distress, anxiety, S/S of hypoxia
Nursing Management:
Prevention:
- Frequent turning and early mobilization
- Deep-breathing exercises at least every 2 hours, IS therapy
- Coughing exercises, suctioning, aerosol therapy, and chest physiotherapy (pulmonary toilet)
Treatment:
- Strategies to improve ventilation and remove secretions
- Ask if they have been traveling, if they have been around sick people, do they smoke, any other medical problems
- Percussion will sound dull
- Goal: able to do ADLs
- Encourage hydration; 2-3 L a day, unless contraindicated
- Humidification may be used to loosen secretions; by face mask or with oxygen
- Oxygen therapy administered to patient needs
- Encourage rest and avoidance of overexertion.
- Patient teaching: sick longer than a week need to be seen. Vaccines: flu, pneumonia shot. Stay away from sick people, No smoking. Lots of fluids.
Assess: LOC, can they maintain airway, VS- might have fever, lung sounds, Do they need to have an airway put in, History of cold or flu recently, chills, cough, SOB, chest pain
Treat: encourage 2-3L of fluids/day, humidification (especially in winter), coughing techniques, position changes ***(sit them up, lay on uneffected side so the effected side can drain), rest in semi-fowlers but also get up and move, nutrition: good calories
Pneumonia Types:
- Aspiration (food, drink, saliva, emesis), inhalation (chemicals, fumes, firefighters), hematogenenous (carried the infections through the blood to the lungs)
- Pneumonia can happen in one lung or both.
- Bacterial: need to finish antibiotics
- Viral: takes 1-3 weeks to get over . 1/3 of all cases in the US are viral
- Fungal: HIV, cancer, anti-rejection, steroids, soils, microplasms, bird poop
- Parasites: rare. Swimming in contaminated water
- Chemicals: chemical plants
- Opportunistic: Pneumocyctis carni pneumonia (PCP)- immunocompromised individuals get this. Legionairres- cooling fountains
Etiology:
- Variety of aspirated organisms.
- Organism dependent on whether community acquired in previously healthy patient (more likely Streptococcus)
- Community acquired in patient with depressed pulmonary defenses such as a patient with chronic bronchitis (more likely Klebsiella or Pseudomonas spps
- Community acquired: if they come in with pneumonia or if they get pneumonia within the first 2 days of admission
- Hospital acquired: nursing home is always considered hospital acquired. If the patient gets it from the facility. Must have symptoms 48 hours after admission
- Often see pneumonia in the winter.
People at risk: Elderly Weak immune system Kids under 2: not mature immune system until 2 Ventilator patients- hospital acquired Smokers Drinkers COPD Stroke patients get pneumonia a lot – may have a low temp instead of a high temp
Diagnostics and Medical Treatment for Pneumonia
Medical Treatment:
- Supportive treatment includes fluids, oxygen for hypoxia, antipyretics, antitussives, decongestants, and possibly, antihistamines.
- Administration of antibiotic therapy is determined by Gram stain results. If the etiologic agent is not identified, use empiric antibiotic therapy.
- Antibiotics are not indicated for viral infections but are used for secondary bacterial infection.
- Occasionally steroids to decrease inflammation
- SOB: FIRST THING SIT THEM UP! THEN GIVE OXYGEN.
- Check O2 sat
- Start antibiotics AFTER culture
- Know the patient is getting better because LOC is improved
- Prevention: vaccine for old and at risk.
Diagnostics: blood gases, blood culture, sputum specimen, chest x-ray, O2 sat, CBG- might have diabetes, CBC- white count, platelets, red count. Bronchoscopy, thorosentesis- needle into lung to pull out fluid or whatever is there.
Collaborative Problems for Pneumonia
Continuing symptoms after initiation of therapy Pleurisy Atelectasis Pleural effusion Bacteremia/sepsis Abscesses Empyema Shock Respiratory failure Confusion Meningitis Pericarditis Respiratory failure Pneumothorax Suprainfection
Tuberculosis
TB most commonly affects the lungs but also can involve almost any organ of the body
- Could have TB of larynx, kidney, bone, breast milk, lymph nodes, brain, liver, heart
- Health care workers are more exposed, and after a while can have a positive test because of the exposure
A person can become infected with tuberculosis bacteria when he or she inhales minute particles of infected sputum from the air
Lung tissue calcification, resulting from pulmonary tuberculosis, appears as yellow patches within the chest area of this human X ray.
When airborne phlegm contaminated with the bacillus Mycobacterium tuberculosis is inhaled, nodular lesions, called tubercles, may form in the lungs and spread through the nearest lymph node.
***Need a sputum specimen to tell if the person has active TB
Pathophysiology:
Inhaled bacillus
Bacteria ingested by macrophages releasing cytochymes
Bacteria resist lysis
Multiplies in the macrophages: Macrophages can travel to other organs
Immune response develops: Forms granulomas
If immune level lowers can reactivate
Clinical manifestations:
Inactive TB – none
Active: Cough x 3 weeks Blood in sputum Chest pain when breathing/coughing Anorexia & weight loss Fatigue Night sweats Chills and low grade fever If active in other parts of body, SS will be there
First symptoms: fatigue, low grade fevers, night sweats
Later symptoms: cough, blood in sputum, chest pain when breathing/coughing, anorexia and weight loss
***Cannot confirm that a patient has TB unless you have a sputum culture!
Diagnostics:
Chest xray/Scans- can tell me if they have had it before
Sputum Culture: early morning collection
PPD testing (Mantoux): can tell me if I have built the antibodies for the disease. Might have a false negative test because the immune system is weak.
Can do a blood draw but it’s very expensive so rarely done
Treatment:
- Untreated active TB will kill about 2 of every 3 people
- Treated tuberculosis has a mortality rate of less than 5% (or less in developed countries where intensive supportive measures are available).
- **The standard “short” course treatment for active TB is **isoniazid, rifampicin, pyrazinamide, and/or ethambutol (can kill the elderly, can impact eye color perception) for two months, then isoniazid and rifampicin alone for a further four months. Cannot have alcohol while on these meds! SE: nausea, vomitting, anorexia, jaundice, itchy because of jaundice, dark urine, fever of unknown origin for 3-4 days at a time.
- The patient is considered cured at six months (although there is still a relapse rate of 2 to 3%). Need 3 culutred that come back negative to say that they are cured.
- For latent TB, the standard treatment is six to nine months of isoniazid alone.
- Husband has it so wife is treated with INH for 6 months
- Resistant strain – antibx for 12-20 months
- May need a lobectomy
- When admitted to the floor, negative pressure room. Air from the hall sucks into the room so that the germs don’t go out into the hallway.
Nursing Management:
Private room with negative airflow
Respiratory isolation until they don’t have a cough
Need to cover face when coughing
Patient understanding of treatment (must take meds for the full 6 months!!!) and prevention
Absence of complications
Continue with medications
Wear mask (the special one they make for you) Patient should wear a mask when they leave the room for tests or procedures
Occupational Lung Diseases
Coal worker’s Pneumoconiosis- black lung. Fibrosis from coal that they breathe in.
Silicosis: Farmers, firemen, dust, fumes, alveoli get scarred
Asbestosis: can occur 10 to 40 years after exposure.
Construction and Navy (ship pipes)
Treatment:
- The goal is to relieve respiratory symptoms, manage hypoxia and cor pulmonale. Includes careful observation for the development of TB.
- Chest physiotherapy techniques: aerosol therapy, inhaled mucolytics, and intermittent positive pressure breathing.
- Other measures include: Increased fluid intake (***at least 3 L daily) Diuretics, cardiac glycosides, and salt restriction may be indicated in cor pulmonale.
- In severe cases, it may be necessary to administer oxygen for hypoxemia by cannula or mask (1 to 2 L/minute)
- Respiratory infections require prompt administration of antibiotics. Need to get treated right away.
Nursing Management:
- Fowler’s position
- Encourage activity- moves fluid in lungs
- Encourage fluids
- Chest physiotherapy
