NU 102 Exam 2 Study Guide

Respiratory Disorders
By Mary Joyce Caballes

✰​Respiratory Tract Disorders​✰

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✰​ Atelectasis ​= ​closure or collapse of alveoli; causes reduced alveolar ventilation

● Can be acute or chronic
○ Acute more common.

● Types:
○ Microatelectasis​ =​ not detectable​ on chest x-rays
○ Macroatelectasis​ = loss of segment, lobar, or overall lung volume
● Causes:
○ Postop:
■ Specific surgical procedures (ex: upper abdominal, thoracic, or open heart surgery)
■ High risk due to monotonous, low tidal breathing pattern which can cause small airway closure and alveolar collapse. This can be
from:
● Shallow respirations, pain, splinting, anesthesia, analgesics, supine position
○ Immobilization
○ Excessive excretions
○ Chronic airway obstruction by secretions from due to impaired cough mechanism or conditions that restrict normal lung expansion on inspiration
(ex: lung cancer)
○ Hypoventilation
○ ↑ abdominal pressure
○ Musculoskeletal or neurological disorders
○ Pressure on lung tissue:
■ Pleural effusion = fluid in pleural space
■ Pneumothorax = air in pleural space
■ Hemothorax = blood in pleural space
■ Elevated diaphragm (abdominal distension)
● Risk Factors:
○ Older age
○ Preexisting resp conditions; COPD
○ Heart failure
○ ↓ level of consciousness
○ Poor functional ability/immobility
○ History of cigarette smoking
○ Malnutrition
● Symptoms:
○ Dyspnea Acute: Chronic:​ (same as acute)
○ Cough • Respiratory distress • Predispose pt’s to pulmonary infections
○ Sputum production • Tachycardia
○ Hypoxemia • Pleural Pain
○ Fever - low grade • Central cyanosis (late sign)
• Difficulty breathing in supine
• anxious
● Assessment & Dx Tests:
○ ↑ breathing
○ Hypoxia (SpO2 <90%)
○ ↓ breath sounds and crackles are heard over the affected area
■ Crackles heard in dependent posterior area of lungs
○ Chest x ray may show atelectasis (​patchy​ infiltrates or​ consolidated ​areas) before symptoms appear
● Prevention/Interventions:
○ Frequent turning from supine to upright
○ Early mobilization from bed to chair followed by early ambulation
○ Expand the lungs:
■ Deep breathing exercises = every 2 hours
■ Incentive spirometer
 ○ Manage Secretions:
■ Deep breathing and cough
■ Suctioning prn
■ Aerosol nebulizer
■ Chest physiotherapy
● Postural drainage
● Chest percussion
■ Bronchoscopy
○ ICOUGH Program:
■ I​ncentive spirometry
■ C​oughing and deep breathing
■ O​ral care (brushing teeth and using mouthwash 2x a day)
■ U​nderstanding (pt and staff education)
■ G​etting out of bed at least 3x daily
■ H​ead of bed elevation
● Treatment/Management:
○ Bronchodilators
■ Nebulizer treatments or MDI
○ Positive end-expiratory pressure (PEEP) = a simple mask and one-way valve system that provides varying amounts of expiratory resistance,
usually 10-15 cm H2O may be needed if pt can’t perform deep breathing exercises.
○ Thoracentesis = removal of fluid by needle aspiration
○ Insertion of chest tube

✰​ Pneumonia (PNA) ​=​ acute infection causing inflammation of lung parenchyma (bronchioles and alveolar spaces)
in one or both lungs caused by various organisms like bacteria, viruses, and fungi.
❖ Air sacs may fill will fluid, mucus, or pus = limits amount of O2 entering sacs
❖ Most serious in infants, young children, 65+, and co-morbidities or weakened immune systems

● Types:
○ Community-acquired pneumonia​ (CAP) = acquired outside hospitals or extended care facilities
○ Hospital-acquired pneumonia​ (HAP) = contracted by pt in hospital at least 48-72 hours after being admitted
■ Presented with a new pulmonary infiltrate on chest x-ray combined with evidence of infection such as fever, respiratory symptoms,
purulent sputum, or leukocytosis.
○ Health Care-associated pneumonia​ (HCAP) = contracted in other health care settings like nursing homes, dialysis centers, and outpatient
clinics
○ Aspiration pneumonia​ = occurs if food, drink, vomit, or saliva is inhaled from mouth to lungs
● Causes:
○ Bacteria = streptococcus pneumoniae
■ **most common cause
■ Usually happens to elderly pt’s 65+
○ Bacteria like organisms = mycoplasma pneumoniae
■ Produces milder symptoms
■ Walking pneumonia = asymptomatic, a typical pneumonia
○ Fungi
■ Common in people with weakened immune system/chronic health problems
■ Fungi found in soil or bird droppings
○ Viruses
■ Cold and flu can cause pneumonia
■ Usually mild, but can become very serious
■ RSV = virus that causes infection of lungs and respiratory tract
● So common that most children have been affected by age 2
■ Human rhinovirus = most common viral infection, common cold
■ Viral pneumonia can lead to bacterial pneumonia
● Risk Factors:
○ Age 65+
○ Alcoholism
○ Beta-lactam therapy (ex: cephalosporins) in past 3 months
○ Multiple medical comorbidities
○ Weakened or suppressed immune system (ex: HIV) or underlying cardiopulmonary disease
○ Residency in long-term care facility
○ Corticosteroid therapy
○ Malnutrition
○ Cigarette smoking
○ Exposure to chemicals, pollutants, toxic fumes
 ○ History of lung disease or other serious disease
○ Limited mobility
● Symptoms:
○ Sudden onset of chills and fever
○ Productive cough or rust colored or purulent sputum = viral dry cough
○ Use of accessory muscles
○ Pleuritic pain = chest pain with cough or breaths
○ ↓ breath sounds, fine ​crackles, rhonchi, wheezes, bronchial breath sounds
○ Nasal flaring
○ Fatigue
○ Lower than normal body temp
○ SOB, dyspnea, tachypnea
○ Cyanosis if air exchange is impaired
○ Confusion or changes in mental status
○ Nausea, vomiting, or diarrhea
○ Older and debilitated pts may be atypical; s&s may be absent or misleading
■ Little resp distress, fever, tachypnea, confusion, or agitation
● Complications:
○ Shock and respiratory failure esp in the elderly
○ Atelectasis
○ Pleural Effusion
○ Empyema = thick purulent fluid accumulated in pleural space
■ Treat with chest tube to drain fluid and 4-6 weeks of antibiotics
● Assessment & Dx:
○ ABG
○ Chest x-rays = shows abnormal density; no clinical way to differentiate bacterial and viral cause
○ Blood and sputum cultures
■ Take sputum early in morning
○ Auscultation = crackles, rales, wheezes, rhonchi, pleural friction rub
● Prevention/Interventions:
○ Promote coughing and expectoration of secretions. Encourage smoking cessation
○ Reposition frequently and promote lung expansion exercises and coughing
○ Oral hygiene
○ Elevate head of bed 30 degrees for pt’s in supine position who can’t protect airway
○ Fluids to liquefy secretions and replace insensible fluid loss from tachypnea and fever
■ 2-3 L a day; caution with elderly for fluid overload
○ Monitor and record intake and output
○ Postural drainage
○ Provide suction
○ Promote rest
○ Incentive spirometer
○ Vaccinations:
■ Pneumococcal pneumonia (Pneumovax, Prevnar, PCV)
● Every 5-7 years in healthy adults
● Pneumococcal (against streptococcal pneumoniae) vaccine lasts for 5 or more years
■ H influenza (Hib)
■ Influenza flu vaccine yearly
● Treatment/Management:
○ Antibiotics
○ For Viral Pneumonia:
■ Supportive only; don’t treat with antibiotics as it ↑ risk of resistance
■ Only use antibiotic with a viral infection when a secondary bacterial pneumonia, bronchitis, or sinusitis is present
■ Influenza Infection - antivirals
● Ex: Amantadine (symmetrel) and rimantadine
● Within 24 hrs of onset of infection
● Helps reduce symptoms and complications
● Best used with the flu vaccine
○ Analgesics
○ Antipyretics
○ Antitussives
■ Antihistamines to reduce sneezing and rhinorrhea
○ Bronchodilators: metaproterenol (Alupent), isoetharine (Brokosol), albuterol (Proventil)
✰​ Pulmonary Tuberculosis ​= ​Infectious disease that primarily affects the lung parenchyma (tissue)
❖ Airborne, infectious, communicable disease caused by Mycobacterium tuberculosis
❖ Airborne via droplet to alveoli and lung lobes via talking, coughing, sneezing, laughing, singing, etc.
➢ may be transmitted to other parts of the body, including meninges, kidneys, bones and lymph nodes.
❖ Initial Infection occurs 2-10 weeks after exposure
❖ not everyone infected with M. tuberculosis becomes sick.
➢ Latent TB infection = bacteria can live in body without making you sick. No symptoms, can become TB disease later on.
❖ Closely associated with poverty, malnutrition, overcrowding, substandard housing, and inadequate health care.

● Risk Factors:
○ Close and prolonged contact with someone who has active TB
○ Immunocompromised pt (ex: HIV, cancer, transplanted organs, prolonged high dose corticosteroid therapy)
○ Substance abuse (IV/injection drug users and alcoholics)
○ Any person without adequate health care
○ Pre Existing conditions (ex: diabetes, chronic kidney injury, malnourishment, selected malignancies, hemodialysis, transplanted organ)
○ Healthcare workers
○ Living in overcrowding, substandard housing
● Symptoms:
○ Maybe asymptomatic
○ Persistent cough (lasts 3 or more weeks)
■ Nonproductive
■ OR mucopurulent sputum or hemoptysis (blood) and copious secretions
○ Low grade fever
○ Night sweats
○ Fatigue
○ Weight loss
○ Failure to gain weight
○ Anorexia
○ Malnutrition
○ Crackles, wheezing
○ Diminished breath sounds
○ Enlarged painful lymph nodes
○ Fremitus = chest vibration with palpation
● Assessment & Dx:
○ Tuberculin Skin Test (Mantoux Test/PPD)​ = used to
determine whether a person has been infected with active or
latent TB
■ Tubercle bacillus extract is injected into the intradermal layer of the inner aspect of the forearm, approximately 4 inches below the
elbow.
■ Result is ready and read after 48-72 hours
■ Look for both redness and induration
● Erythema without induration is ​not​ considered significant
● Size of induration is significant and determines if person has TB
○ > 5 mm = is significant in pt’s with HIV, close contact with TB, other high risk pt
○ > 10 mm = significant in pt’s who have normal or mildly impaired immunity
■ Significant reaction = indicates past exposure to M. tuberculosis or vaccination with bacille Calmette-Guerin (BCG) vaccine
● Vaccine is given to produce greater resistance to development of TB
■ In older adults, it may not produce a reaction or it can be delayed for up to 1 week
● Second skin test is performed in 1-2 weeks
○ TB Blood Tests (QuantiFERON-TB Gold and T-Spot)​ = test for BCG vaccine
■ Results are available 24-36 hours
■ Positive IGRA (blood test) needs additional tests
○ Sputum culture​ = done to confirm dx
○ Chest X-ray = confirms presence of pulmonary TB
○ Gastric Washings = in children under 12 years because they don’t produce sputum.
■ Early morning after overnight fast
■ 3 consecutive days confirms positive pulmonary TB
● Prevention/Interventions:
○ Fluids to liquefy secretions and promote airway clearance
○ Small frequent feeding due to fatigue and debilitated state
○ Progressive activity and muscle strengthening
○ Oral care
○ Postural drainage
○ Make sure pt is adhering to prescribed treatment regimen
○ Educate importance of hygiene, covering mouth and nose when sneezing, coughing, etc.
○ Diet high in carb, proteins
● Treatment/Management:
○ Emphasize importance of takin meds on empty stomach or 1 hour before meals
○ Teach pt about risk of drug resistance if medication regimen isn’t followed
○ TB must be treated for at least 6 to 9 months. Several drugs must be used to treat TB disease.
○ First-Line Meds for Active TB: ​(multiple medication regimen)
■ Isoniazid (INH)
● Route​ = PO/IM daily for 9 months
● S&S ​= hepatotoxicity, flu like symptoms, neuropathy, hypersensitivity
● Considerations​:
○ Give pyridoxine (Vit B6) = to prevent/decrease peripheral neuropathy (tingling and numbness in fingers/toes
■ INH ↓
○ Monitor AST and ALT
○ Should​ avoid ​foods that contain: tyramine and histamine
■ Ex: tuna, aged cheese, red wine, soy sauce, yeast extracts
■ This is because it can cause headache, flushing, hypotension, lightheadedness, palpitations, and
diaphoresis
■ Rifampin
● Combinations:​ Rifamate (INH + rifampin)
● Route:​ PO/IV; PO daily for 4 months
● S&S:
○ Orange discoloration of urine ​(expected) and other secretions
○ Nausea and vomiting
○ Hepatitis
○ Sun sensitivity
○ Febrile reaction
○ Purpura (rare)
○ ↓ levels of many drugs
○ ↑ metabolism of oral contraceptives, corticosteroids, coumadin, digoxin, and oral hypoglycemic
● Monitor AST and ALT
● Considerations:
○ makes ​birth control pills and implants less effective.
■ Women who take rifampin should use another form of birth control.
○ can cause withdrawal symptoms for pt taking methadone (used to treat drug addiction).
■ Persons who take rifampin and methadone may need their methadone dosages adjusted.
○ can alter the metabolism of certain other medications, making them less effective.
■ Beta-blockers, oral contraceptives
○ Can ​discolor contact lenses​ = tell pt to wear eyeglasses during treatment
■ Pyrazinamide
● Route:​ PO for 8 weeks
● S&S:
○ Hepatotoxicity
○ hyperuricemia
○ Arthralgia
○ Skin rash
○ GI irritation
● Monitor uric acid, AST, ALT
● Considerations:
○ caution in patients who are diabetics, have kidney problems, or gout (bc the med increases uric acid levels)
■ Ethambutol
● Route: PO, 2x weekly
● S&S:
○ Optic neuritis
○ ↓ visual acuity
■ Report any blurred or color change
■ Always assess pt’s vision
○ Impaired red-green color discrimination
○ May lead to blindness
○ Skin rash
■ S&S to watch for all drugs:
● Hepatitis, hearing loss, rash
● Monitor BUN and creatinine
■ Streptomycin
● Route:​ IM, 2x weekly
● S&S​: ototoxicity, nephrotoxicity, hypokalemia
✰​ Pleural Effusion ​=​ Collection of fluid in the pleural space.
❖ Normally, the pleural space contains small amount which acts as a lubricant and allows pleural surfaces to move without friction
❖ Rarely a primary disease process, usually secondary to other diseases
➢ CHF, TB, pneumonia, pulmonary infections
❖ Fluids can be clear (transudate or exudate), bloody, or purulent
➢ Transudate = usually implies pleural membranes are not diseased
■ Most common from CHF
➢ Exudate = from inflammation by bacterial products or tumors involving pleural surfaces

● Symptoms:
○ Caused by underlying disease:
■ Pneumonia = fever, chills, pleuritic chest pain
■ Malignant effusion = dyspnea, difficulty lying flat, coughing
○ Severity of symptoms determined by size of effusion, speed of its formation,
and underlying lung disease:
■ Large pleural effusion = dyspnea, acute respiratory distress with
trachea deviating away from affected side
■ Small to moderate = minimal or no dyspnea
● Assessment & Dx:
○ ↓ or absent breath sounds
○ ↓ fremitus (vibration intensity felt on chest wall)
○ Dull, flat sound on percussion
○ Chest x-ray
○ AFT stain (for TB)
○ RBC & WBC count
○ Pleural biopsy
● Prevention/Interventions:
○ Prep pt for thoracentesis
■ Record amount/characteristics drained and send for lab testing
○ Monitor chest tube drainage and water-seal and record amount as prescribed in intervals
○ Care for underlying cause
○ Pain management
○ Educate pt and family about management and care of catheter and drainage system
● Treatment/Management:
○ Treat underlying cause (HF, pneumonia, cirrhosis)
○ Prevent reaccumulation of fluid
○ Relieve discomfort, dyspnea, and respiratory compromise
○ Thoracentesis = needle inserted into pleural space to remove excess fluid
○ Chest tube connected to water-seal drainage system or suction to evacuate pleural space and expand lung
○ If underlying cause is a malignancy, effusion tends to recur within a few days or weeks
■ Once pleural space is drained, a chemical pleurodesis may be performed to obliterate the pleural space and prevent re-accumulation
of fluid
● Pleurodesis = process of instilling a chemically irritating agent into pleural space to promote formation of adhesions
between visceral and parietal pleura
■ Surgical pleurectomy = insertion of small catheter attached to drainage bottle for outpatient management
■ Pleuroperitoneal shunt = 2 catheters connected by a pump chamber containing 2 one-way valves
● Fluid moves from pleural space to pump chamber and then to peritoneal cavity
● Pt manually pumps on reservoir daily to move fluid from pleural space to peritoneal space

✰​ Pleurisy (pleuritis) ​=​ inflammation of both layers of pleurae (parietal and visceral)
❖ Can develop due to PNA or upper resp tract infection, TB, chest trauma, after a thoracotomy and PE
❖ Pain worsens on inspiration, with coughing, and or sneezing

● Assessment & Dx:

○ Pleural friction rub
○ Sputum analysis
○ thoracentesis
● Prevention/Interventions:
○ Enhance comfort: turn the patient on the affected side to splint the chest wall to prevent stretching of the pleura.
○ Use pillow to splint the rib cage while coughing
● Treatment/Management:
○ Administration of analgesics, heat/cold, NSAIDs
○ Monitor for S&S of pleural effusion
✰​ Empyema ​=​accumulation of thick, purulent fluid within the pleural space.
❖ Occurs as complication of bacterial PNA or lung abscess

● S&S:
○ Pt is acutely ill and has S&S similar to acute respiratory infection or PNA
■ fever, night sweats, pleural pain, cough, dyspnea, anorexia, weight loss
● Assessment & Dx:
○ decreased/absent breath sounds
○ Dullness on chest percussion
● Prevention/Interventions:
○ Lung expansion exercises
○ Assist in drainage removal
● Treatment/Management:
○ Drain pleural cavity to complete expansion of lung
○ Antibiotics are administered in large doses (4-6 weeks)

✰​ Pulmonary Embolism ​=​ obstruction of the pulmonary artery or one of its branches by a thrombus (or thrombi)
that originates somewhere in the venous system or in the right side of the heart.
❖ Venous thromboembolism (VTE) includes both DVT (thrombus form in calf, thigh, arm) and PE.
❖ PE is commonly due to blood clot, air, fat, amniotic fluid, and septic
❖ Associated with trauma, surgery, pregnancy, HF, 50+ years, prolonged immobility

● S&S:
○ Dyspnea (most frequent symptom) • Diaphoresis
○ Sudden chest pain • Hemoptysis
○ Substernal pain (mimic angina pectoris or a MI) • Syncope
○ Fever • Tachypnea (most frequent sign)
○ Tachycardia • Rapid and weak pul\se
○ Cough • Anxiety
○ Shock • Swollen leg
● Assessment & Dx:
○ Death from acute PE commonly occurs within ​1 hour after​ onset of symptoms
■ Early recognition is a MUST
○ Chest x-ray = may show infiltrates, atelectasis, elevation of diaphragm on affected side, or pleural effusion
○ ECG = abnormal with sinus tachycardia; peaked P waves; inverted T waves
○ Pulse ox
○ ABG = hypoxemia and hypocapnia (from tachypnea) or it can be normal
○ Ventilation-Perfusion scan (V/Q) = use a contrast agent that evaluates different regions of lung and allows comparisons of the % of V/Q in each
area
○ Multidetector-row computed tomography angiography (MDCTA) = provides advantage of high quality visualization of lung cellular tissues
○ D-dimer = blood test for evidence of blood clots
■ Normal d-dimer, PE is ruled out
○ Pulmonary angiography = allows direct visualization under fluoroscopy of arterial obstruction and accurate assessment of perfusion deficit
● Prevention/Interventions:
○ Active and passive leg exercises to avoid venous stasis
○ Legs should not dangle; should rest on floor or chair
○ Early ambulation
○ Anti-embolism stockings
○ Elevate leg
○ IV catheters shouldn’t be left for prolonged periods
○ Semi-fowler position = for chest pain, however turn pt’s frequently
○ Oxygen therapy
○ Relieve anxiety
● Treatment/Management:
○ EMERGENCY management:
■ Give nasal oxygen = relieve hypoxemia, resp distress, and central cyanosis
■ Endotracheal intubation = for severe hypoxemia
■ Mechanical ventilator support
■ IV infusion lines
● Hypotension ont resolved by fluids = give vasopressor therapy (dobutamine, dopamine, norepinephrine)
■ Pulse ox/ABG/MDCTA
■ ECG = monitor dysrhythmias and right ventricular failure
 ■ Blood draw = F&E, CBC, coagulation studies
■ Urinary catheter = if massive emboli to monitor I&O
■ IV morphine/sedatives = for pt anxiety, chest pain, and improve tolerances to chest tube
○ Pharmacologic Management​:
■ Anticoagulation Therapy
● Immediately given to pt is suspected of PE
● Initial anticoagulant:
○ Low molecular weight heparin ​(enoxaparin = Lovenox)
■ Initial, but not long term
● Long term indicated from 10 days to 3 months following PE or indefinitely for pt’s who are high risk for recurrence
● Give warfarin for long term therapy
○ Monitor INR
○ Have Vit K available and if risk of bleeding
■ Thrombolytic Therapy:
● Used in pts with acute PE who have hypotension and don’t have a contraindication or potential bleeding risk
● Obtain INR, PTT, hematocrit, and platelet counts first
● Anticoagulant is stopped prior to administration of a thrombolytic agent
● Fresh whole blood, packed RBC, or frozen plasma is given to replace blood loss
● After thrombolytic infusion is completed, maintenance anticoagulation therapy is initiated
● Contraindications:
○ Stroke within past 2 months
○ Active bleeding
○ Active intracranial processes
○ Surgery within 10 days of thrombotic event
○ Recent labor or delivery, trauma, or severe hypertension
■ Surgical Management:
● Embolectomy = can be performed using catheters or surgically
○ Pt needs to be on cardiopulmonary bypass with a cardiovascular surgical team
○ Monitor pulmonary arterial pressure and urinary output
○ Assess insertion site for hematoma and infection
○ Maintain BP
● Inferior Vena Cava (IVC) Filter = filter provided a screen in the IVC allowing blood to pass through while large emboli
from pelvis or lower extremities are blocked or fragmented before reaching lung
○ Last resort

✰​ Lung Cancer ​=​ Most common cause of lung cancer is inhaled carcinogens, most often cigarette smoke (> 85%);
other carcinogens include radon gas and occupational and environmental agents.
❖ Lung cancer can metastasis to the bone, brain, adrenal gland, or liver
❖ Small Lung Cancer = 15% of tumors; small cell and combined small cell
❖ Non-small Lung Cancer (NSCLC) = 85% of tumors, squamous cell,
➢ Stages:
■ Stage I = earliest and has ↑ cure rate; localized in lung
■ Stage II = lung and localized in lymph nodes
■ Stage III = spread throughout lung, lymph nodes, and/or opposite lung
■ Stage IV = metastatic spread; both lungs, surrounding tissues and/or distant organ

● Risk Factors:
○ Environmental
■ tobacco, secondhand smoke, e-cigs
■ environmental and occupational exposures
● Pollutants, motor vehicle emissions, radon, arsenic, asbestos, etc)
■ Genetic predisposition
■ Dietary deficits
■ Underlying respiratory diseases (COPD, TB)
● S&S:
○ Develops gradually and is asymptomatic until late in its course
○ S&S depends on location and size of tumor, degree of obstruction, and existence of metastases to regional or distant sites
○ Common sites of metastases:
■ Lymph nodes, bone, brain, adrenal glands, liver, and contralateral lung
○ Most frequent​:
■ Cough or ​change in chronic cough
■ Cough may be dry, persistent, without sputum production
 ○ Early Signs​:
■ Recurring fever
■ dyspnea
○ Late Signs​:
■ Tight chest or shoulder pain
■ Neck swelling
■ Pleural effusion
○ Other Signs​:
■ Hemoptysis
■ Hoarseness, dysphagia, head and neck edema
■ Weight loss, anorexia
■ Bronchospasms = wheezing with partial obstruction by tumor
■ Fatigue = related to treatments
● Assessment & Dx:
○ Chest x-ray = for pulmonary density, atelectasis, pulmonary nodule and induction
○ Sputum specimen = for cytological exam
■ First morning sputum for presence of malignant cells
○ Bronchoscopy = visualize and obtain tissue for biopsy
○ CT scan & MRI = identify small nodules and the brain for CNS metastases
○ Fiberoptic bronchoscopy = provides detailed study of tracheobronchial tree
○ Transthoracic fine-needle aspiration = to aspirate cells from suspicious area
○ PET scan and liver ultrasound = to assess for metastasis of cancer
○ CBC, liver function studies = electrolytes (CALCIUM), evidence of metastasis
● Prevention/Interventions:
○ Address physiologic (resp manifestations of disease) and psychological needs of
pt
○ Ensure pain relief and discomfort to prevent complications
○ educate pt and family about potential side effects of treatments and strategies to
manage them
○ Airway clearance techniques:
■ Deep breathing
■ Chest physiotherapy
■ Directed cough
■ Suctioning
■ Bronchoscopy
■ Supplemental O2
■ Semi-fowler
○ Reduce fatigue
○ Provide psychological support
● Treatment/Management:
○ Surgery Resection​:
■ Recommended for localized NSCLC
■ Lobectomy = single lobe of lung is removed
■ Bilobectomy = 2 lobes of lung are removed
■ Sleeve Resection = cancerous lobe (s) is removed and segment of main bronchus is resected
■ Pneumonectomy = removal of entire lung
■ Segmentectomy = segment of lung is removed
■ Wedge resection = removal of small, pie-shaped area of segment
■ Chest wall resection = removal of cancerous lung tissue; for cancers that have invaded chest wall
○ Radiation Therapy​:
■ Controls neoplasms that can’t be surgically resected
■ Reduce tumor size in order to operate or relieve pressure on vita structures
■ Radiation is toxic to normal tissue and may lead to complications
■ Can relieve:
● Cough • hemoptysis
● Chest pain • bone and liver pain
● dyspnea
○ Chemotherapy​:
■ Alter tumor growth patterns, treat distant metastases or SCLC, and as an adjunct to surgery or radiation therapy
■ Provides relief but doesn’t cure
■ S&S/Monitor:
● Hair loss • monitor hypoxemia
● Monitor breathing patterns • sleep disturbances
● Poor nutrition • Reduce fatigue caused by pain/discomfort
● Anemia
○ Palliative therapy​:
■ To shrink tumor to provide pain relief
✰​ Pneumothorax ​=​ Parietal or visceral pleura are breached (opened) and the pleural space is exposed
to positive atmospheric pressure and the lung collapses. Free air enter the pleural space)

● Types:
○ Simple or Spontaneous​ = air enters the pleural space through an
opening in the visceral or parietal pleura
■ Can occur in healthy lung tissue due to a rupture of an
air-filled bleb (small air blisters which can burst
allowing air to leak into space that surrounds lungs))
or with COPD or emphysema
○ Traumatic​ = laceration in lung or trauma wound to chest wall
(ex: rib fracture, stabbing, subclavian line, thoracentesis,
mechanical ventilation)
■ Commonly associated with hemothorax = blood in
pleural space
■ Hemopneumothorax = both blood and air
○ Open pneumothorax = form of traumatic, occurs when chest
wound is large enough to allow air to pass freely in and out of
thoracic cavity with each respiration
■ Rush of air produces sucking sound
■ Emergency interventions
○ Tension Pneumothorax ​= complication of pneumothorax
■ Air enters lung from a wound in chest wall or
lacerated wall
■ Air that enters with each inspiration is trapped and
can’t be expelled during expiration through the wound
in chest
■ A one way valve is formed where air enters pleural
space but can’t escape
■ With each breath, tension ↑ in the pleural space
causing lung to collapse and the heart, great vessels,
and trachea to shift toward the unaffected side
● Causes ↓ venous return and CO
● Symptoms:​ hypoxemia, agitation,
hypotension, tachycardia, shock
● Treat:​ Oxygen and immediately decompress with a large bore ( 14 gauge ) followed by a chest tube
● S&S:
○ May have only minimal resp. distress
○ Lung may totally collapse with large pneumothorax causing severe resp distress = air hunger
○ See symptoms of tension pneumothorax
○ ↓ movement of affected side of chest wall
○ ↓ breath sounds
○ Tachypnea, SOB
○ Use of accessory muscles
○ Sudden or gradual onset of pain; sharp pain
○ Anxiety
○ Can develop central cyanosis from severe hypoxemia
● Assessment & Dx:
○ Chest x ray = air or blood in pleural space
○ Auscultation
○ CT scan
● Prevention/Interventions:
○ Bed rest
○ Oxygen supplementation
● Treatment/Management:
○ Insert Chest Tube = evacuate air, blood from pleural space
○ For open sucking traumatic chest wounds = stop flow of air through wound
■ Use towel, handkerchief, or heel of hand, Vaseline gauze pad with pressure dressing until chest tube is inserted
○ Thoracentresis = needle aspiration
✰​ Cardiac Tamponade ​=​ compression of the heart resulting from fluid or blood within the pericardial sac
❖ may follow diagnostic cardiac catheterization, angiographic procedures, and pacemaker insertion = can perforate the heart and great vessels

● Causes:
○ Blunt or penetrating trauma to chest
■ A penetrating wound of the heart is associated with a high mortality rate
● Symptoms:
○ Acute:
■ Chest pain • JVD
■ Tachypnea, dyspnea • Feeling of pressure in chest
■ Muted heart sound • hypotension
○ With hypotension pt can develop pulses paradoxus = a systolic BP that is lower during
inhalation
■ Characterized by abnormal difference of at least 10 mm Hg in systolic pressure
between point that is heard during exhalation and that is heard during inhalation
● Assessment & Dx:
○ Echocardiogram = confirm dx and quantify amount of pericardial fluid
○ Chest x-ray = show enlarged cardiac silhouette due to pericardial effusion
○ ECG = tachycardia and low voltage
● Treatment/Management:
○ Pericardiocentesis​ = puncture of pericardial sac to aspirate pericardial fluid
■ Pt is monitored by continuous ECG and frequent VS
■ Relieved cardiac tamponade is indicated with:
● ↓ in CVP and associated ↑ in BP after withdrawal of pericardial fluid
● Pt almost always feels immediate relief
■ Complications:
● Coronary artery puncture, myocardial trauma, dysrhythmias, pleural
laceration, and gastric puncture
■ Monitor: HR, BP, venous pressure, and heart sounds after performing
○ Pericardiotomy​ = open surgical drainage (last resort)
■ For recurrent pericardial effusions
■ With general anesthesia, a portion of the pericardium is excised to permit the exudative pericardial fluid to drain into lymphatic
system

✰​ SubQ Emphysema ​=​ results after chest trauma when lung or air passages are injured
● Air gets into tissues under skin
● Usually occurs in skin covering the chest wall or neck, but can also occur in other parts of the body
● Often can be seen as a smooth bulging of the skin
● When palpated, the skin produces an unusual crackling sensation as the gas is pushed through the tissue
○ This gives an alarming appearance as the face, neck, body and scrotum become misshapen by sucq air
● For severe cases a tracheostomy is indicated if airway patency is threatened by pressure of the trapped air in the trachea
✰​ Chronic Bronchitis ​=​ disease of the airways; excessive bronchial mucus secretion and cough for at least 3 months in 2 consecutive years
❖ Pt develops narrowed airways, impaired ciliary function, recurrent infection, pulmonary HPT, right-sided heart failure

● Factors:
○ Inflammation and ↑ airway mucus secretion​:
■ Smoke and environmental pollutants
■ Constant irritation = causes gland and goblet cells to ↑ in number which ↑ mucus
production
○ Bronchial walls thicken​:
■ Narrowing occurs of bronchial lumen
■ Pt becomes susceptible to respiratory infection which can produce acute episodes
of bronchitis
● Exacerbation most likely to occur in winter
● Symptoms:
○ Dyspnea
○ Cyanosis
○ Prolonged expiration
○ Scattered crackles, rhonchi, and wheezing
○ Cardiac dysrhythmias
○ ↑ mucus production
○ Chronic, productive cough
○ ↑ anterior-posterior diameter
○ Peripheral edema
○ Respiratory acidosis
○ Evidence of right-sided heart failure:
■ Neck vein distention, edema, liver engorgement, enlarged heart
✰​ Emphysema ​=​ Characterized by destruction of alveolar walls from overdistended alveoli
❖ Progresses slowly for many years
❖ As walls of alveoli are destroyed = alveolar surface area in direct contact with pulmonary capillaries continually ↓. This causes:
➢ an ↑ in dead space = no gas exchange occurs
➢ Impaired O2 diffusion = leads to hypoxemia
❖ In later stage, CO2 elimination is impaired. This results in:
➢ ↑ CO2 tension in arterial blood (hypercapnia) = leads to respiratory acidosis

● Tyes:
○ Panlobular = destruction on respiratory bronchiole, alveolar duct, and alveolus
■ All airspaces within lobule are enlarge, but there is little inflammatory disease
■ Hyperinflated chest, marked dyspnea on exertion, and adequate level of positive
pressure must be attained and maintained during expiration
■ Expiration becomes active and requires muscular effort
○ Centrilobular = changes take place mainly in center of secondary lobule
■ There is a derangement of ventilation-perfusion ratios
■ Produces chronic hypoxemia, hypercapnia, polycythemia (↑ in RBC), and
episodes of right-sided heart failure
■ This leads to central cyanosis and respiratory failure
■ Pt also develops peripheral edema
● Symptoms:
○ Dyspnea pm exertion (gradual onset) which progresses to severe at rest
○ Barrel chest​ = due to loss of chest elasticity causing ribs to become rigid and fixed in
inspiratory position
○ Use of accessory muscles
○ ↑ AP diameter of chest (1:1)
○ ↓ breath sounds with expiratory wheezes
○ SOB
○ Weight loss (from breathing)
○ Pt may​ look “pink and puffy”
○ Tachypnea
○ Leans forward while sitting
○ Breathing through pursed lips
○ Fatigue
○ absent or decreased breath sounds, possible crackles, wheezes, or rhonchi

✰​ COPD ​=​ Chronic obstructive pulmonary disease is a group of conditions causing the chronic or recurrent obstruction of airflow.
❖ Can result from the combination of symptoms associated with: ​1) ​chronic bronchitis ​2.)​ emphysema and ​3)​ asthma
❖ Pt’s with COPD commonly become symptomatic during the middle adult years which ↑ in incidence with age
❖ It if progressive and associated with the lungs abnormal inflammatory response to noxious particles or gases
❖

● Risk Factors:
○ Exposure to tobacco smoke and secondhand smoke (passive)
○ ↑ age
○ Occupational exposure - dust, chemicals
○ Indoor and outdoor air pollution
○ Genetic abnormalities including:
■ Deficiency of alpha=antitrypsin, an enzyme inhibitor that normally
counteracts the destruction of lung tissue by certain other enzymes
○ Allergies and recent pulmonary infection
● Assessment & Dx:
○ Pulmonary function tests
○ Serum alpha-antitrypsin level = screen for deficiency
○ ABG = ↓pao2; ↑pco2
○ Spirometry
○ CBC with differential /↑ RBCs and hematocrit
■ Due to chronic hypoxia
○ ↑ WBC with infection
○ Chest x-rays = shows flattening of diaphragm due to hyperinflation, presence
of infection.
 ○ Bronchodilator Reversibility Testing​ = to rule out asthma (acute) vs chronic bronchospasms
■ Spirometry obtained first
■ Then inhale bronchodilator
■ Then repeat spirometry
■ Indicates it’s reversible if pt improves after treatment
○ Peak Expiratory Flow Rate = will measure expiratory ability and help assess condition improvement after treatment
● Treatment/Management:
○ Stop smoking; nicotine therapy
○ Remain inside during times of significant air pollution; air filters and air conditioning
○ When dusting, use a wet cloth
○ Percussion and postural drainage
○ Avoiding cough suppressants and sedation
○ Regular exercise program
○ Changing eating habits so he or she eats small, frequent meals rather than large meals
■ High calorie, high protein
○ Request referral to pulmonary rehabilitation and encourage patients to learn how to improve activity tolerance and perform ADLs with less
dyspnea
○ Breathing exercises to slow respiratory rate and relieve accessory muscle fatigue
■ Pursed-lip breathing = slow expiration and prevent collapse of small airways and improve alveolar ventilation by expelling as much
air as possible, ↓ air trapping
■ Inspiratory muscle breathing against resistance
● Conditioned muscles use less O2
■ Directed “huff” coughing
■ Incentive spirometer
■ Deep breathing exercises
○ Hydration = Saline or water aerosol mists
○ Avoid temperature extremes = heat ↑ body temp, raising O2 needs; cold promotes bronchospasm
○ Inhalation = route of choice because it allows for topical relief and acts quickly
■ Ex: MDI, spacers
○ Oxygen Supplementation​:
■ Pt with COPD who is CO2 retainer responds to ↓ levels of O2 as stimulus to breathe
■ Giving high flow rates of O2 will ​↓ all stimulus to breathe and ↑ CO2
● ***Use with caution!
● low flow rate recommended​ (​1-2 L/min​)
■ Long term therapy used for severe, progressive hypoxemia
■ Indications for O2 therapy are PaO2 of 55 or less
■ Goal is to keep SpO2 >90%
○ Medications​:
■ Bronchodilators → corticosteroids →mucolytics
■ Bronchodilators = reduce airway obstruction, ↑ O2
■ Anti-inflammatory meds
● Ex: corticosteroids (used more in asthma than COPD)
■ Antibiotics PRN
■ Mucolytics
■ Antitussives
■ Vaccinations:
● Hib Vaccine
● Influenza vaccine = yearly
● Pneumococcal (PCV) = every 5-7 years
○ Surgery​:
■ Bullectomy = used for bullous emphysema
● Bullae may be surgically excised to reduce dyspnea and improve lung function

✰​ Asthma ​=​ Chronic disease characterized by reversible obstruction of airflow due to inflammation and narrowing of the airways.
❖ Causes airway hyperresponsiveness, mucosal edema, and mucus production
❖ Inflammation leads to = recurrent episodes of asthme
➢ Cough, chest tightness, wheezing, and dyspnea
❖ Acute and can be chronic and is largely reversible, either spontaneously or with treatment
❖ Most often at night or early morning
❖ Initially: hypocapnia and respiratory alkalosis because breathing very rapidly
❖ May be symptom free with exacerbations lasting minutes to days

● Risk Factors:
○ Allergy = Chronic exposure to airway irritants ↑ risk
■ Seasonal: grass, tree, weed pollen
■ Perennial: mold, dust, roaches, animal dander
 ○ Air pollutants • Cold, heat, weather changes
○ Strong odors or perfumes • Smoke and occupational exposure
○ Foods, exercise, stress, hormonal factors • Medications, viral resp tract infections, GERD
● Symptoms:
○ Asthma attacks often occur at night or early in morning
○ Cough (with or without mucus production) • tachycardia
○ Dyspnea • widened pulse pressure
○ Wheezing (first on expiration, then inspiration) • hypoxemia/central cyanosis (late sign)
○ Prolonged expiratory time • airway “remodeling” in chronic inflammation
○ Chest tightness • ↓ SpO2
○ Diaphoresis • accessory muscle use
○ Tripod positioning • nasal flaring
● Assessment & Dx:
○ Peak Expiratory Flow Rate​ (PEFR) = maximal forced expiratory flow
■ Daily Peak Flow Monitoring - peak flow meter
(spirometer) measures ability to push air forcefully out of
the lungs.
■ Meds administration and effectiveness of treatment can be
based on peak expiratory flow rate (PEFR).
■ The “personal best” is determined after monitoring PERF
2-4 times per day for 2-3 weeks after receiving optimal
asthma therapy.
● Prevention/Interventions​:
○ Monitor VS
○ Monitor pulse ox and peak flow
○ During an acute episode: use interventions to assist with breathing
○ ↓ anxiety (stay with pt)
○ Administer meds = bronchodilators/corticosteroids
○ Record color, amount, and consistency of sputum if any
○ Auscultate lungs before during and after
○ Helpful breathing techniques
○ Position pt’s body for optimal air exchange
○ Assess for dehydration = administer IV fluids (check skin turgor for
dehydration and to loosen secretions)
○ Conservation of energy
○ Avoidance of triggers/respiratory irritants
○ Educate pt:
■ Smoking cessation
■ Important of exercise
■ Need to cough up sputum
● Treatment/Management:
○ Asthma Action Plan ​= based on peak flow measurements
■ Provides instruction on recognition of early S&S of
worsening asthma and self management:
● Green​ = 80-100% personal best
○ Breathing is good and pt is doing well
○ No coughing, wheeze, SOB, chest
tightness
○ Sleep through night
○ Can work and play
○ Action: use preventative meds
● Yellow​ = 50-80% personal best
○ Asthma is getting worse
○ Pt may have cough, wheezing, chest
tightness, SOB
○ May wake up at night due to asthma
○ Implement action plan
● Red ​= < 50% personal best
○ Indicates medical alert
○ Pt is very SOB
○ quick relief meds might not work
○ pt may not be able to do usual activities
○ Symptoms are same or get worse after
24 hours in yellow zone
○ Implement action plan and call MD if they don’t return to yellow or green
○ Fluids ​= pt is frequently dehydrated from diaphoresis and insensible fluid loss with hyperventilation
■ 2-4 L/day unless contraindicated
○ Oxygen PRN ​= keep pulse ox at > or - 92%
 ○ Medications​:
■ Quick relief meds = for immediate treatment of asthma symptoms and exacerbations
● First used to prompt relief of airflow obstruction
● Short acting beta 2 adrenergic agonists
● Anticholinergics
■ Long acting meds = to maintain control of persistent asthma
● Corticosteroids
● Long acting beta 2 adrenergic agonists
● Leukotrienes
■ immunomodulators
● Status Asthmaticus​ =asthma attack of such severity that it is considered a medical emergency. It can lead to respiratory failure and death.
○ Attacks last longer than 24 hours
○ Often precipitated by an upper respiratory infection, illicit drug use, an allergic reaction, exercising in cold weather, recent tapering of
corticosteroid use, or exposure to air pollution, mold, or dust.
○ Initially ABGs show hypoxemia and respiratory alkalosis with a ↓ CO2 from tachypnea
○ As they worsen, CO2 ↑ (**danger sign of impending resp failure as pt is becoming fatigued with slower respiration; pt may need a ventilator)
○ As obstruction worsens, the wheezing may disappear
○ S&S​:
■ Dyspnea, labored breathing ⬛ ​chest tightness
■ Prolonged exhalation ⬛ ​engorged neck veins
■ Wheezing ⬛ ​↑ mucous production
■ Dry cough ⬛ ​agitation/restlessness
■ Tachypnea ⬛ ​rapidly worsening SOB

✰​ Obstructive Sleep Apnea ​=​ characterized by recurrent episodes of upper airway obstruction and a reduction in ventilation.
❖ Defined as cessation of breathing (apnea) during sleep usually caused by repetitive upper airway obstruction
❖ Interferes with people’s ability to obtain adequate rest
❖ Affects = memory, learning, and decision making which results in hypoxia and hypercapnia

● Risk Factors:
○ Obesity
○ Male gender
○ Postmenopausal status
○ Advanced age
● Symptoms:
○ 3 S’s = snoring, sleepiness, and significant other report of sleep apnea
○ Loud snoring with breathing cessation for 10 sec or longer
■ At least 5 episode/hr followed by awakening abruptly with loud snort as the blood oxygen level drops
■ Often happens during REM stage of sleep
○ Excessive daytime sleepiness • frequent nocturnal awakening •polycythemia
○ Insomnia • morning headaches • enuresis
○ Intellectual deterioration • personality changes, irritability • dysrhythmias
○ Impotence • systemic hypertension • pulmonary hypertension, cor pulmonale
● Assessment & Dx:
○ Overnight study polysomnographic (sleep study​)
■ Performed in a specialized sleep disorders center which measures physiologic signals while pt sleeps
● Prevention/Interventions:
○ Weight loss
○ Positional therapy
○ Oral appliance = mandibular advancement devices (MADs)
○ CPAP/BiPAP severe cases
■ BiPAP = supplemental O2 therapy via nasal cannula and result in a lower average airway pressure
● Used with hypoxemia and severe hypercapnia
■ CPAP = used to prevent airway collapse
● Treatment/Management:
○ Meds​:
■ Modafinil (provigil) = reduce daytime sleepiness
■ Protryptilin (triptil) = at bedtime to ↑ resp drive and improve upper airway muscle tone
■ Not a substitute for CPAP and BiPAP
○ Surgical Management​:
■ Simple Tonsillectomy = effective for pt with large tonsils when other options have failed
■ Uvulopalathopharyngoplasty = resection of pharyngeal soft tissue and removal of 15 mm of free edge of soft palate and uvula
■ Tracheostomy = relieves upper airway obstruction
● Side Effect: speech difficulty and ↑ risk of infection