Chronic Respiratory Disorders

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Chapter 31

• Chronic Respiratory Disorders

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Learning Objectives

• Identify examples of chronic inflammatory,
  obstructive, and restrictive pulmonary diseases.
• Explain the relationship between cigarette
  smoking and chronic respiratory disorders.
• For selected chronic respiratory disorders,
  describe the pathophysiology, signs and symptoms,
  complications, diagnostic measures, and medical
  treatment.
• Assist in developing a nursing care plan for the
  patient who has a chronic respiratory disorder.

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Asthma
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Pathophysiology

• Potentially reversible obstructive airway
  disorder airway inflammation and
  hyperresponsiveness

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Pathophysiology Acute Episode

• Begins when triggers activate the inflammatory
  process
• Airways constrict and become edematous
• Mucous secretion increases, forming plugs in the
  airways, and tenacious sputum is produced
• Obstruction causes air to be trapped in the
  alveoli, creating a ventilation-perfusion
  mismatch
• Effect is hypoxemia with compensatory
  hyperventilation
• Acute episodes begin within 30 to 60 minutes
  after exposure to trigger and resolve 30 to 90
  minutes later

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Figure 31-1
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Pathophysiology

• Late phase
• Begins 5 to 6 hours after the early phase
  response
• Red and white blood cells infiltrate swollen
  tissues of the airways
• During this phase, which lasts several hours or
  days, the airways are hyperreactive (very
  sensitive)
• Risk for another episode until phase subsides
• When no specific trigger can be identified, the
  patient may be said to have intrinsic asthma
• Asthma with known triggers extrinsic asthma

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Signs and Symptoms

• Dyspnea, productive cough, use of accessory
  muscles of respiration, audible expiratory
  wheezing, tachycardia, and tachypnea

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Medical Diagnosis

• Health history, the physical examination, and the
  pulmonary function test results

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Medical Treatment

• Bronchodilators
• Anti-inflammatory drugs

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Figure 31-2
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Assessment

• Essential information (medications, allergies,
  known cardiac disease, sleep disruption)
  immediately take steps to relieve symptoms
• Health history
• Frequency and severity of attacks, the factors
  known to trigger attacks, effect of condition on
  patients life, strategies used to manage the
  condition, sources of stress and support, and
  patients knowledge about asthma and its treatment

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Assessment

• Physical examination
• Measurement of vital signs and auscultation of
  lung sounds
• Assess skin color and respiratory effort

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Interventions

• Ineffective Breathing Pattern
• Impaired Gas Exchange
• Anxiety

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Chronic Bronchitis and Emphysema
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Pathophysiology

• Chronic bronchitis
• Bronchial inflammation increased production of
  mucus and chronic cough that persist for at least
  3 months of the year for 2 consecutive years and
  by impaired ciliary action
• Cause inhaled irritants, e.g., cigarette smoke
• Cor pulmonale right-sided heart failure
  secondary to pulmonary disease

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Figure 31-3
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Pathophysiology

• Emphysema
• Degenerative, nonreversible disease enlargement
  of the airways beyond the terminal bronchioles
• Centrilobular emphysema
• Associated with cigarette smoking affects mainly
  the respiratory bronchioles
• Panlobular emphysema
• Affects the respiratory bronchioles and the
  alveoli

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Figure 31-4
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Complications

• Respiratory failure
• Factors infection, air pollution, continued
  smoking, left ventricular failure, myocardial
  infarction, pulmonary embolism, spontaneous
  pneumothorax, and adverse effects of drugs

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Signs and Symptoms

• Chronic bronchitis
• Productive cough, exertional dyspnea, and
  wheezing
• Emphysema
• Dyspnea on exertion
• Increased anteroposterior diameter

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Figure 31-5
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Figure 31-6
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Figure 31-7
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Medical Diagnosis

• Patients health history and physical examination
• Pulmonary function tests
• Computed tomography (CT) scan

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Medical Treatment

• Drug therapy
• Goals improved ventilation and removal of
  secretions
• Bronchodilators
• Corticosteroids

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Medical Treatment

• Oxygen therapy
• Initial is usually 1 to 3 L/minute
• Chest physiotherapy
• Exercise
• Nutrition
• Supplementary feedings may be needed
• Good hydration
• Treatment of respiratory failure
• Oxygen therapy, aerosol bronchodilators, chest
  physiotherapy, and mechanical ventilation

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Surgical Treatment

• Lung volume reduction surgery (LVRS)
• Up to 30 of hyperinflated lung tissue excised to
  improve mechanics of breathing, enabling patient
  to breathe more deeply
• Bullectomy (removal of bullae)
• Lung transplantation

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Assessment

• Describe the presenting symptomsoften dyspnea,
  cough, chest pain, or a combination of these
• Obtain a complete medical history
• List of current medications and drug allergies

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Assessment

• Physical examination
• Posture, color, respiratory effort, and use of
  accessory muscles of respiration measure vital
  signs
• Hypoxemia restlessness, confusion, and lethargy
• Inspect neck for distention of veins
• Shape of the thorax for the classic barrel chest
• Auscultate lung fields for diminished breath
  sounds
• Inspect the nails for clubbing, pallor, or
  cyanosis
• Inspect and palpate the feet and ankles for
  edema note muscle wasting

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Interventions

• Impaired Gas Exchange
• Ineffective Airway Clearance
• Anxiety
• Imbalanced Nutrition Less Than Body Requirements
  
• Risk for Infection
• Activity Intolerance
• Decreased Cardiac Output

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Figure 31-8
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Bronchiectasis

• Abnormal dilation/distortion of bronchi and
  bronchioles usually confined to one lung lobe or
  segment
• Follows recurrent inflammatory conditions,
  infections, or obstructions but is sometimes
  congenital
• Signs coughing, production of large amounts of
  purulent sputum
• Also fever, hemoptysis, nasal stuffiness, sinus
  drainage, fatigue, and weakness
• Goals control symptoms and prevent spread
• Treatment antibiotic therapy, bronchodilators,
  chest physiotherapy, and oxygen therapy

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Cystic Fibrosis

• Hereditary disorder characterized by dysfunction
  of the exocrine glands and production of thick,
  tenacious mucus
• Cough is the first pulmonary symptom
• Becomes productive of thick, purulent sputum
  obstructs airways
• Results in obstruction of the pancreatic ducts so
  that pancreatic enzymes cannot be delivered to
  the GI tract

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Cystic Fibrosis

• Stools become bulky and foul smelling
• Lose more salt in sweat than normal at risk for
  salt depletion, especially in hot environments
• Over years, symptoms progress increased dyspnea,
  decreased exercise tolerance, and weight loss
• Airway obstruction and decreased resistance to
  infections lead to chronic bacterial infections,
  emphysema, atelectasis, and respiratory failure

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Cystic Fibrosis

• Treatment
• Pancreatic enzyme replacement, chest
  physiotherapy, and aerosol and nebulizer
  treatments to reduce mucus viscosity
• Infections treated with antibiotics

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Cystic Fibrosis

• Nursing care
• To clear airway administer prescribed
  medications, maintain hydration, and perform
  chest physiotherapy
• Prevent infection with medical asepsis and
  protect patient from others with infections
• Maintain adequate nutrition administer
  pancreatic enzymes as ordered, allow for rest
  around mealtimes, and encourage to consume
  adequate nutrients

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Tuberculosis
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Etiology and Risk Factors

• An infection caused by Mycobacterium
  tuberculosis, an acid-fast aerobic bacterium
• Spread by droplets from infected people during
  coughing, laughing, sneezing, and singing
• Anyone may become infected, but most healthy
  people not through brief contact
• At increased risk elderly, economically
  disadvantaged and homeless, substance abusers,
  children younger than 5 years, the
  immunosuppressed, racial and ethnic groups

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Pathophysiology

• Most people do not acquire active (symptomatic,
  progressive) tuberculosis
• Bodys immune response attempts to destroy the
  infecting organisms, but some may escape into the
  lymph nodes or throughout the body
• The site of the primary infection may undergo
  necrotic degeneration

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Pathophysiology

• Cavities develop that are filled with infectious
  material, which eventually liquefies and is
  coughed up as sputum
• In some, infectious process progresses, and
  active tuberculosis develops
• It is possible for inactive bacteria to be
  reactivated, causing illness later

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Signs and Symptoms

• Cough, night sweats, chest pain and tightness,
  fatigue, anorexia, weight loss, and low-grade
  fever

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Medical Diagnosis

• History and physical examination
• Sputum cultures, acid-fast smears of potentially
  infected body fluids, tuberculin skin tests, and
  chest radiographs

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Medical Treatment

• Common preventive treatment is isoniazid therapy
  for 9 to 12 months
• Individuals with inactive tuberculosis may be
  treated with INH alone, INH with rifampin, or
  rifampin with pyrazinamide

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Assessment

• A complete health history and a physical
  examination

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Interventions

• Impaired Gas Exchange
• Social Isolation
• Risk for Injury
• Fatigue
• Imbalanced Nutrition Less Than Body Requirements
  
• Ineffective Therapeutic Regimen Management

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Interstitial Lung Disease

• Inflammation of the lower respiratory tract and
  thickening and fibrosis of the alveolar walls
  render the alveoli nonfunctional
• May be caused by inhaled substances or connective
  tissue disorders sometimes no specific cause
  identified
• Examples idiopathic pulmonary fibrosis
  (occupational lung diseases), sarcoidosis

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Idiopathic Pulmonary Fibrosis

• Pathophysiology
• Formation of scar tissue in lung tissue after
  inflammation or irritation
• Cigarette smoking, frequent aspiration, or
  exposure to environmental or occupational
  substances
• Complications
• Pulmonary hypertension, cor pulmonale, and
  ventilatory failure

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Idiopathic Pulmonary Fibrosis

• Signs and symptoms
• Nonproductive cough and progressive dyspnea
• Inspirational crackles heard in the lungs on
  auscultation
• Clubbing of the fingertips

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Idiopathic Pulmonary Fibrosis

• Medical treatment
• Corticosteroids, bronchodilators, and oxygen
  therapy
• Also cytotoxic drugs and antifibrotic agents
• Interventions
• Similar to those described for the patient with
  COPD

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Occupational Lung Diseases
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Acute Respiratory Irritation

• Inhalation of gases such as ammonia or chlorine
• Effects usually temporary, but if the lower
  airways are affected, pulmonary edema or alveolar
  damage and airway obstruction
• May have coughing, wheezing, and dyspnea
• Symptoms resolve within a few days to several
  weeks usually no permanent lung damage
• Treatment managing symptoms and avoiding exposure

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Occupational Asthma

• Inhalation of plant or animal proteins cause an
  allergic reaction
• Treatment same as for bronchial asthma
• Initial acute symptoms last only a few hours, but
  patient may have hyperreactive airway for years
• This means that future exposure to irritants may
  trigger acute asthmatic symptoms
• Patient should avoid continued exposure to the
  offending substance

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Hypersensitivity Pneumonitis

• Allergic inflammatory response of the alveoli to
  inhaled organic particles
• May resolve in a few days, or patient may
  contract pulmonary edema or interstitial fibrosis
  with permanent restrictive or restrictive-obstruct
  ive disease
• Treated with corticosteroids and avoidance of
  irritants respiratory support may be needed if
  symptoms are severe

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Pneumoconiosis

• Caused by inhalation of various dusts
• In response to repeated exposure to silica,
  asbestos, or coal dust characterized by diffuse
  pulmonary fibrosis and restrictive lung disease
• Aggravated by cigarette smoking advised to avoid
  offending dust and cigarette smoke
• Otherwise, treatment is symptomatic

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Chronic Restrictive Pulmonary Disorders
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Sarcoidosis

• Pathophysiology
• Inflammatory condition affects the skin, eyes,
  lungs, liver, spleen, bones, salivary glands,
  joints, and heart
• An unknown factor triggers a series of immune
  processes leads to formation of clusters of
  cells and debris in affected tissues called
  granulomas
• Signs and symptoms
• Some have no symptoms, others experience dry
  cough, dyspnea, chest pain, hemoptysis, fatigue,
  weakness, weight loss, and fever

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Sarcoidosis

• Medical diagnosis
• Chest radiography, pulmonary function tests, and
  flexible bronchoscopy with transbronchial lung
  biopsy
• Medical treatment
• If patient is asymptomatic, no treatment is
  indicated
• 6- to 12-month course of systemic corticosteroids
  
• Methotrexate used as an alternative to
  corticosteroids
• Lung transplantation only option for patients
  with end-stage disease who do not respond to drug
  therapy

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Sarcoidosis

• Nursing care
• Monitoring for progressive dysfunction and
  teaching about corticosteroid therapy
• Care of the patient with severe pulmonary
  symptoms is similar to that for patients with COPD

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Lung Cancer

• Etiology and risk factors
• Leading cause of cancer death in the United
  States
• Cigarette smoking leading cause
• Risk increased more for smokers exposed to other
  carcinogenic substances, such as arsenic,
  asbestos, and radioactive materials
• Evidence that secondhand smoke a threat to
  nonsmokers

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Lung Cancer

• Pathophysiology
• Small cell (oat cell) lung carcinoma (SCLC)
• Nonsmall cell lung carcinoma (NSCLC)
• Squamous cell carcinomas, adenocarcinomas, large
  cell carcinomas, and bronchial carcinoids
• Small cell and large cell undifferentiated
  carcinomas grow rapidly other lung cancers grow
  slowly
• All can metastasize to other body organs
• SCLCs, which grow rapidly, tend to metastasize
  early
• Can invade the pericardium, causing pericardial
  effusion and possibly triggering dysrhythmias

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Lung Cancer

• Signs and symptoms
• Persistent cough, hemoptysis, chest pain, and
  recurring pneumonia or bronchitis
• May have dyspnea, weight loss, and pain in the
  shoulder, arm, or hand
• Other signs and symptoms may be related to
  metastatic lesions

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Lung Cancer

• Medical diagnosis
• Radiographic procedures (chest radiography, CT
  scan, MRI), fiberoptic bronchoscopy, sputum
  cytology studies, and biopsy of tissue obtained
  through bronchoscopy, percutaneous transthoracic
  fine-needle biopsy, thoracotomy, or other methods
  
• Radionuclide scans of bones, liver, or brain to
  detect metastatic lesions

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Lung Cancer

• Medical treatment
• Radiotherapy
• Chemotherapy
• Targeted biologic therapies
• Surgical treatment
• Wedge resection, sleeve lobectomy, segmental
  resection, lobectomy, or pneumonectomy

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Figure 31-9
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Lung Cancer

• Nursing care
• Nurses must continue to educate the public about
  the dangers of cigarette smoking to help
  eliminate the primary cause of lung cancer

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Extrapulmonary Disorders

• Chest deformities interfere with lung expansion
• Neuromuscular diseases such as myasthenia gravis
  and amyotrophic lateral sclerosis affect the
  muscles of respiration
• Head or spinal cord injuries can disrupt the
  breathing center in the brain or the neural
  control of the diaphragm
• Heart failure with pulmonary edema fills lungs
  with fluid, interfering with the exchange of gases

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Figure 31-10