Med/Surg 2: Respiratory System

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CT with contrast, check allergies to:

seafood and iodine

Pulmonary angiogram

to visualize pulmonary vasculature
contrast injected through central venous catheter into right side of heart an pulmonary artery
identifies circulation alterations (congenital, embolism, tumor)
ass for iodine/seafood allergy

Ventilation-perfusion scan

radioactive isotope injected to identify areas of ventilation and perfusion

lowered pulse ox accuracy with:

brightly lit environment, acrylic fingernails/nail polish, dark skin color

pulmonary function tests (PFTs)

spirometer to measure volumes and capacities during forced breathing
assesses effects of bronchodilator therapy

bronchoscopy

can be used on people on RA, O2, and mechanical ventilation
preprocedure: NPO 6-12 hous, informed consent obtained, analgesia/sedation, topical/local anesthesia applied to nasal, pharyngeal areas

post: assess for return of gag**, assess for laryngeal edema (hoarseness, stridor, dyspnea, vital signs, chest pain)

Thoracentesis

needle inserted into thoracic cavity to withdrawal pleural fluid for analysis or drain pleural effusion

sputum collection

expectoration, suctioning, saline-induced specimen, thoracentesis, lung needle biopsy, transtracheal aspiration

TB

acid-fast bacilli; collected 3 different days, following long sleep period is preferable (early morning) due to high concentrations. may also collect gastric specimen since TB is not effected by acid environment of stomach
10mm induration indicates exposure, 5mm in immunosuppressed

Airway management: opening airway

head tilt, chin lift
UNLESS suspected neck injury.. then jaw thrust

Endotracheal intubation

sized for individual
LUNG AUSCULTATION immediately after placement should yield bilaterally equal breath sounds
proper placement confirmed by x-ray as soon as possible

positioning for unilateral lung disease

"good lung down"
bad lung stays on top

positioning for acute respiratory failure

elevate head 45 degrees

acute respiratory distress sydrome

prone maybe attempted with pts on maximal mechanical ventilation with unresponsive hypoxemia (makes air gravitationally flow to air filled alveoli instead of previously dependent fluid filled alveoli)
caution with ET tube

O2 via nasal cannula at 1-6 L/min will give concentrations of:

24-44% O2
room air is 21%
each Liter increases % by about 4

COPD and oxygen

should receive low concentrations (1-2 L/min) to prevent respiratory depression due to loss of respiratory drive

face mask oxygen

levels similar to o2, mask should be greater than 5 L/min to minimize rebreathed CO2
concentration of 40-60%

face mask with O2 reservoir

constant flow of O2 into attached bag, minimizes CO2 rebreathing
6-10 L/min
60-100% o2
for those who need high concentrations but can't get ET

venturi mask

most control over exact concentration given
24, 28, 35, and 40% oxygen
COPD and chronic co2 retention

purpose of pursed lip breathing (during exhalation)

slows down exhalation speed and reduces airway collapse by increasing pressure

huff coughing

client attempts sequential coughing while saying "huff"
keeps glottis open during coughing
COPD benefitted

Chest PT

indication: greater than 30mL secretions per day, secretions with artificial airway, and atelectasis

contraindications: lung cancer, hemoptysis, bronchospasm

postural drainage

contraindicated 1 hour before and 3 hours after a meal to reduce risk of vomiting/aspiration

Tracheostomy precautions

use aseptic technique when suctioning or cleaning

keep trach tube obturator at head of bed for reinsertion if accidental dislodgment
manual ventilation bag connected to oxygen at bedside
unused trach tube at bedside for immediate use

airborne precautions

TB, rubeola, varicella
client in monitored negative air pressure room with door closed
N95 respirator for TB, and nonimmune/suseptible persons for rubeola and varicella
client wears surgical mask when transported

droplet precautions

large organisms spread when person coughs, sneezes, or talks
masks when working within 3 feet
client wears surgical mask when transported
air handling not necessary, door may remain open
other pts with same organism and no other infections may be in same room

post thoracic surgery norms

compare baseline vitals, lung sounds, expansion, oxygenation
75-100 mL of chest drainage over 1 hours is an average UPPER limit
proper analgesics facilitate lung expansion and ventilation

purpose of chest tube

reestablish negative intrathoracic pressure following surgery, trauma, pneumothorax
to drain blood, pleural effusion, or infected organism (empyema)

care of chest tube

occlusive dressing at insertion site
secure tube to system with heavy tape, and all connection tubing
apparatus below the level of the chest
NEVER clamp or milk

water seal chamber

prevents air and drainage from flowing back into the chest
filled to 2 cm marking
can fluctuate with breathing
CANNOT BE INTERUPTED

emergency treatment of tension pneumothorax

one-way valve (heimlich valve)
catheter-over-needled inserted into 2nd intercostle space, needle removed, hissing is heard as air escapes into atmosphere.
creates simple pneumothorax
chest tube and system after ASAP to fix this problem

positioning after lobectomy

back, or turned to either side

position after segmental resection

"good side down"
lying on back, turned onto nonoperative side
(positioning on operative side may put tension on sutures and cause bleeding)

positioning after pneumonectomy

lying on back, or operative side down
AVOID SHIFTS COMPLETELY TO EITHER SIDE

Chronic Obstructive Pulmonary Disease (COPD)

two types: emphysema, chronic bronchitis

emphysema ("pink puffers")

destruction of alveoli related to chronic inflammation resulting in decreased surface area for gas exchange
airway collapse due to loss of elasticity in system tissues

caused by smoking
occupational factors (coal, glass, asbestos)
hereditary deficiency of alpha1-antitrypsin

symptoms of emphysema

difficulty exhaling (airways obstructed with edema or mucus)
lung hyperinflation causes alveolar air trapping and frequent infections

barrel chest appearance
excess accessory muscle use due to WOB
under weight (lot of energy to breathe, less eating)
pursed lip breathing (COPD)
persistent tachy due to poor oxygenation
diminished breath sounds, wheezes, crackles
progresses with disease

emphysema diagnostic findings

respiratory acidosis later (CO2 retentions, high pCO2)
CXR hyperinflated lungs, flattened diaphragm
PFTs: low vital capacity and forced expiratory volume

emphysema therapy

remove polutants
bronchodilators
beta adrenergic agonists
anticholinergics: ipratropium (atrovent) (most effective bronchodilator for COPD)
corticosteroids
oxygen/nebulizers
chest pt
fluids
oral care
immunization against pneumonia q5 years and influenza

chronic bronchitis "blue bloaters"

form of COPD
chronic airway inflammation
chronic productive cough lasting at least 3 months during 2 years
chronic inflammation causes hyperplasia of mucous glands (excessive sputum production)
cilia disappear, airwar clearance function lost
goblet cells develop in terminal bronchioles, also increasing sputum
repeat infections due to increased sputum and decreased airway clearance
polycythemia develops (increased RBC) in response to hypoxemia

chronic bronchitis symptoms

frequent cough
foul smelling sputum
WOB
frequent pulmonary infections
obesity and bluish-red skin
dyspnea and activity intolerance
increased anterior-posterior chest diameter
increased risk for DVT with polycythemia

chronic bronchitis diagnostics

CXR: enlarged heart, congested lungs, normal-flattened diaphragm
^RBC, Hemoglobin, Hematocrit

asthma causes

intrinsic etiologies: uncertain; physical/psychological stress, exercise-induced
extrinsic etiologies: allergic reaction to irritants
air pollutants
sinusitis
cold/dry air
medications
food additives
hormonal influences
gastroesophageal reflux

asthma

widespread spasms of bronchiole smooth muscle with airway edema
excessive secretion of thick mucous
hyperinflation of lungs and air trapping

asthma symptoms

severe dyspnea, accessory muscle use
WHEEZING WITH EXPIRATION, if severe may be no wheezing
cough
chest tightness
prolonged expiration
mild to greatly diminished breath sounds
increased HR & BP
restlessness, anxiety, agitation

diagnostics during asthma attack

respirator alkalosis (mild), decreased po2
elevated eosinophil & IgE count (allergic immunoresponse)

asthma meds

inhaled beta agonists, bronchodilators, anti-inflammatory agents, corticosteroids, and o2

teach pt to use peak flow daily for self-assessment

restrictive pulmonary diseases

pleural effusion, empyema, chylothorax

pleural effusion

accumulation of fluid in the pleural space, fluid comes from capillaries
transudative pleural effusion: fluid contains small amount of protein
occurs with heart failure, liver disease and chronic renal disease
exudative: fluid contains large amount of protein
inflammatory response causes it; pulmonary tumors, infections, emboli, pancreatitis, ruptured esophagus

empyema

pleural fluid containing pus
associated with pneumonia, lung abscess, tuberculosis

chylothorax

lymph fluid in pleural space (disruption during surgery or trauma to lymph vessels)
produces fat malabsorption from GI tract

restrictive pulmonary disease symptoms

same as pneumonia
chest wall pain
fever, persistent cough, night sweats, and w eight loss with empyema ( like pneumonia )
visible on xray if greater than 250 mL
thoracentesis to differentiate source of fluid

pneumothorax

spontaneous pneumo: rupture of bleb lets air in pleural space
primary pneumothorax: happens to otherwise healthy individual; most often tall, slender males age 20-40
Secondary pneumothorax: rupture of overdistended alveoli in COPD pt
tension pneumothorax: disruption of chest wall or lungs causes accumulation of air in pleural space (causes pressure on mediastinum, other lung, and lessens venous return to the heart)
traumatic pneumo: blunt or penetrating trauma to pleura, bronchi, or lung
iatrogenic pneumo: disruption of pleura, bronchi, or lung tissue during instrumentation for central venous line placement, lung biopsy, or thoracentesis

tension pneumo

MEDICAL EMERGENCY
chest tube placement immediately to release air and restore cardiac function

hemothorax

blood accumulation in pleural space

pneumo/hemothorax manifestations

dyspnea
tracheal deviation to unaffected side
diminished breath sounds on affected side
dullness on affected side
unequal chest expansion (reduced on affected side)
crepitus (grating, crackling, popping sounds) over chest

atelectasis

alveolar collapse due to airway obstruction and increased pressure in alveli
low-grade fever
diminished breath sounds over area
diminished rate and depth of respiration

most common pneumonia organism

gram-positive streptococcus pneumoniae bacteria

viral pneumonia symptoms

low-grade fever
nonproductive cough
WBC normal-low elevation
CXR: minimal changes evident
less severe than bacterial

bacterial pneumonia symptoms

high fever
productive cough
WBC: high elevation
CXR: obvious infiltrates
most severe clinical course

mycobacterium tuberculosis

any tissue can be infected, most often the lung
gram-positive acid fast bacillus, airborn droplet transmission
cell mediated immunity reacts, produces a granuloma lesian wth Ghon tubercle that oozes liquified necrotic material containing the disease which can be expelled into the air

TB manifestations

frequent cough with copious frothy pink sputum (starts with nonproductive cough early in the morning)
NIGHT SWEATS
anorexia
weight loss

TB tests

mantoux first
CXR shows Ghon tubecles
acid-fast bacillus sputum cultures provide definitive diagnosis

TB prophilactic medications

Isoniazid (INH) for 6 months if no evidence of disease process
INH for 12 months if abnormal chest xray or high-risk population (HIV or drug induced immunosuppression)

Active TB medications

1) INH, rifampin (Rifadin), pyrazinamide (Tebrazid) and ethambutol (Myambutol) or streptomycin daily or 2-3 times weekly for a minimum of 6 months, therapy continued at least 3 months after first negative sputum culture
minimum of 9 months with HIV, continued at least 6 months after first negative sputum culture

INH side effects

hepatotoxicity, peripheral neuritis (numbness, take vitamin B6), hematologic effects (anemia, agranulocitosis, bleeding), hypersensitivity

Rifampin side effects

monitor CBC, LFTs and renal status
orange discoloration of body fluids

Pyrazinamide side effects

hepatotoxicity, high uric acid levels (assess for gout)

Ethambutol side effects

optic neuritis (esp. red/green color discrimination)

pulmonary embolism

risk factors; immobility, hypercoagulability, trauma to the endothelial layer of vessels, long bone fractures (fat emboli), pregnancy

pulmonary emboli manifestations

restlessness, anxiety, agitation
tachycardia, tachypnea, hypotension, fever
chest pain
hemoptysis (cough up blood)
mental status change, decreased LOC
cyanosis
lung crackles on auscultation
afib

tests for pulmonary emboli

spiral/helical CT scan or pulmonary angiogram

bronchogenic carcinoma (lung cancer)

leading cause of death by malignancy
small cell or non-small cell
often starts in bronchus and migrates
smoking

lung cancer symptoms (occur late in disease)

persistent cough (with or without hemoptysis)
localized chest pain
dyspnea
unilateral wheeze
swallowing difficulty
anorexia
weight loss
enlarged neck lymph nodes

tests

mass on cxr
ct or mri can differentiate mass
sputum culture has tumor cells
bronchoscopy for biopsy

medical management

surgical resection (pneumonectomy, lobectomy, segmentectomy, wedge resection)
chemotherapy
radiation therapy
laser therapy
immunotherapy

cancer of the larynx

most laryngeal tumors are benign
most common form of malignant laryngeal cancer is squamous cell carcinoma
causes: cigarette and alcohol consumption

manifestations for laryngeal cancer

hoarseness
palpable jugular nodes
change in voice
pain when swallowing
unexplained earache

tests for laryngeal cancer

biopsy, xray, mri, ct, barrium swallow

treatment

radiation therapy
brachytherapy (placement of radioactive source next to tumor site)
chemotherapy
laryngectomy
radical neck dissection

blunt thoracic trauma

injury to chest wall without disruption of pleura
rib fractures, flail chest, soft tissue rupture (diaphragm, trachea, bronchi, major blood vessels), tension pneumo, contusion of heart and lungs

penetrating thoracic trauma

injury involving disruption of the pleura
internal wounds communicate with external atmosphere
open air-sucking wounds
pneumothorax/hemothorax
tissue wounds (heart/lungs/major vessels)

symptoms of flail chest

(multiple rib fractures in two places, seperated from bony skeleton)
paradoxical chest expansion (with breathing)

rupture of diaphragm

abdominal contents dislocate upward into thoracic cavity
decreased control of breathing

symptoms of trauma

chest pain
shallow breathing with splinting
tachycardia, tachypnea, hypotension
crepitus over chest
possible unequal chest expansion

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