GERI chapter 22 respiratory function

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-- Mechanics -- loss of elastic recoil (increased reserved volume)
-- Oxygenation -- decreased cardiac output, increased physiologic dead space, reduced CO2 diffusion capacity
-- Control of ventilation -- decreased responsiveness of central and peripheral chemoreceptors to hypoxemia and hypercapnia
-- Lung defense mechanisms -- decreased number of cilia, decreased cough reflex, decreased IgA production, decreased ability to clear secretions, increased risk of aspiration
-- Sleep and breathing -- decreased ventilatory drive, upper airway muscle tone, and arousal. Obstructive sleep apnea.
-- Exercise capacity -- muscle deconditioning, decreased muscle mass, decreased maximum oxygen consumption
-- Breathing pattern -- decreased responsiveness to hypoxemia and hypercapnia, increased respiratory rate (16 to 25 breaths per minute) they are faster and shallower.
Cough-- The cough mechanism is altered because of the loss of elastic recoil and decreased respiratory muscle strength -- CAUSES -- in older patients include: postnasal drip, chronic bronchitis, acute respiratory tract infections, aspiration, gastroesophageal reflux disease (GERD), congestive heart failure, interstitial lung disease, Cancer, and angiotensin converting enzyme inhibitors medications for hypertension and CHFObstructive lung diseaseIt is characterized by changes in expiratory air flow rates and obstruction of the airway The lumen may be decreased by mucus, it email the airway lining, or constriction of the muscles surrounding the airway causing broncoconstictionRestrictive lung diseaseCharacterized by decreased ability to expand the chest, impaired inhalation, and decreased lung volumes. Asthma, bronchogenic carcinoma, And tuberculosisAsthmaChronic inflammatory disease that affects the airways and it's characterized by reversible airway obstruction, Airway inflammation, and increased airway responsiveness to a variety of stimuli. It has a higher morbidity and mortality rates in older adults S/S Dyspnea tachycardia Audible wheezing Tachypnea Palpitations diaphoresis Use of accessory muscles of respiration Chest hyperinflation (barrel chest) Falling PaO2 and pH with rising PaCO2 are indicative of imminent respiratory failureLong-term control meds for asthma-- They are taking daily and include anti-inflammatory agents, long-acting bronchodilators, and leukotriene modifiers -- Corticosteroids -- are the most potent and effective long-term control medications in the treatment of mild, moderate, or severe persistent asthma. They reduce airway inflammation, improve the peak flow rate, and diminish airway hyperresponsiveness. They're generally inhaled twice a day Rinse mouth after inhaling to prevent thrush salmeterol ( Servant Diskus) formoterol (Foradil) -- Leukotrine modifiers -- they act on the Longs, coughing airway smooth muscle contraction an increased mucus secretion. They improve lung function, diminish symptoms and reduce the need for SABA's montelukast (Singulair)Quick relief medication for asthma-- Used to treat acute symptoms and exacerbations such as chest tightness, coughing, and wheezing. -- SABA's, anti-cholinergics, and systemic corticosteroids -- They're bronchodilators that provides smooth muscle relaxation within 30 minutes and are the drug of choice for treating acute asthma. -- Older patients who use more than one canister per month do not have adequate control and need additional and inflammatory therapy -- Daily use of SABA's it's not recommended Anticholinergics -- ipratropium bromide (Atrovent)Assessment and diagnosis of asthma-- Assessment -- -- Palpation and percussion of the chest are indicated so that increased tactile fremitus, Chest wall movement, and diaphragmatic excursion can be assessed. -- Pulmonary function tests (PFTs) -- are used to measure the presence and amount of airway obstruction -- Diagnoses -- The diagnosis is based on episodic symptoms of airflow obstruction that are partially reversible. 1.- wheezing 2.- history of a cough that is worse at night 3.- recurrent difficulty breathing and chest tightness 4.- variation in PEFR of 20% or more 5.- symptoms that worsen during exercise, With viral infection, in the presence of environmental irritants, Changes in weather, airborne chemicals, or dust, during menses, or with strong emotional expression hey noChronic bronchitis-- Is is a clinical syndrome characterized excessive mucus production with a chronic or recurrent cough almost days for a MINIMUM OF 3 MONTHS OF THE YEAR FOR AT LEAST 2 CONSECUTIVE YEARS -- Cigarette smoking is the single most important factor that exacerbates chronic bronchitis -- Clinical symptoms include a persistent cough, dyspnea on exertion, purulent sputum, cyanosis, crackles on auscultation, tachycardia, pedal edema, unexplained weight gain, and decreased PaO2 within normal or elevated PA CO2Emphysema-- Usually occurs between 60 and 70 years old -- Progressive distraction of the alveoli and their supporting structures --Physical signs include the classic barrel chest appearance on the use of accessory muscles of respiration --S/S -Dyspnea on exertion or at rest, decreased weight, a chronic cough with little sputum production, digital clubbing, hyperresonance of the chest on percussion, crackles and wheezes on auscultation -- There is no gas exchange because of damaged alveoliCOPD-- It is a progressive airflow limitation that is not fully reversible and, during the course of the disease, lung tissue that becomes abnormally inflamed. -- Peripheral airway inflammation, airway fibrosis, hypertrophy of smooth muscles, hyperplasia of goblet cells and resultant mucus hypersecretion -- CHRONIC BRONCHITIS, EMPHYSEMA, ASTHMA --It is progressive and ultimately fatal disease Chronic coughing is often the first sign of COPDCOPD signs and symptomsChronic and progressive dyspnea, coughing, and sputum productionCOPD treatment with bronchodilatorsThey're the central tool used in managing the symptoms of COPD. They may be prescribed for long-term maintenance or short-term exacerbations. InhaledCOPD treatment with Beta2-agonists-- They should be used with caution in the older patient with ischemic heart disease. -- They stimulate the beta2-receptors in the Lungs which results in broncodilation -- Albuterol (proventil, Ventolin)COPD treatment with anticholinergics-- A combination of an SABA and an anti-cholinergic results in a greater and more sustained improvement than with either drug alone. -- Inhailed anti-cholinergic -- ipratropium bromide (Atrovent) -- They inhibit vagal stimulation of the lungs, preventing contraction of the smooth muscle and decreasing mucusCOPD treatment with glucocorticoidsteroids-- Inhaled glucocorticoidsteroids do not reduce the decline of the older adult with COPD, But for those patients with advanced disease (stage 3 or 4), they have been shown to reduce the frequency of exacerbations and improve overall health statusCOPD treatment with vaccinesInfluenza vaccines reduce both morbidity and mortality rates in patients with COPD by 50%COPD treatment with oxygen therapyLong term oxygen therapy increases survival rates and improves hemodynamics, exercise and lung capacity, and mental status. The primary goal of oxygen therapy is to increase baseline PaO2 to at least 80 mm Hg and SaO2 to at least 90%COPD assessment and diagnoses--This is the hallmark symptom of COPD. -- Spirometry remains the primary tool in determining the severity and staging of COPDRespiratory interventions-- Maximizing the effects of bronchodilator therapy -- Administering medications at designated intervals -- Promoting hydration -- Good nutrition -- Increased motilityPulmonary rehabilitationPrograms are designed to provide the patient with exercise training, breathing retraining, Education, smoking cessation, medications, and nutrition information Exercise 20 to 30 minutes of moderate intensity exercise 3 to 5 times a week Best exercise is walkingSmoking cessation* ASK -- identify users at every visit. For every patient tobacco usage is queried and documented * ADVISE -- strongly urge them to quit. Be clear. Be caring. Be personable. * ASSESS -- determine the patient's readiness to quit. Ask every patient at every opportunity if he or she is willing to try to quit * ASSIST -- help patient with a quick plan. Provide counsel. Provide support. Set a specific date. Help obtain treatment. Help patient with approved pharmacotherapy * ARRANGE -- schedule follow up contact either in person or by phoneDiaphragmatic breathing1.- Lie in supine or semi Fowler position 2.- Place one hand on the middle of the stomach below the sternum 3.- Place the other hand on the upper chest 4.- Inhale slowly through the nose. The stomach should expand. Note the movement of the hand over the stomach 5.- Exhale slowly through pursed lips (stomach should contract) 6.- Rest 7.- RepeatPursed lip breathing1.- assume comfortable position 2.- inhale slowly through the nose, keeping the mouth closed 3.- remember to use the diaphragmatic breathing technique 4.- pucker the lips as if blowing out a candle, kissing, or whistling 5.- exhale slowly, blowing through purse lips (exhalation should be at least twice as long as inhalation) 6.- Rest 7.- RepeatEffective coughing techniquesCascade cough (forcefully) Huff cough (glottis open - say huff while coughing) End-expiratory cough (exhale slowly- cough once at end) Augmented cough (tighten knees and butt)Lung cancer-- It is the leading cause of cancer death, accounting for 28% of cancer deaths -- Risk factors include tobacco use, marijuana use, recurring inflammation, or exposure to asbestos, talcum powder, or minerals -- SMALL-CELL LUNG CARCINOMA: accounts for 20% of the cases. It Is the most lethal and aggressive that metastasizes to the central nervous system, bones, and liver. Five year survival rate of 6.3% -- NON-SMALL_CELL LUNG CARCINOMA: including squamous cell carcinoma and adenocarcinoma which accounts for 79% -- Sputum cytology is used to determine the cell type -- PFTs (pulmonary function test) are used to determine impairment in ventilation and help predict functionality surgery is a consideration -- Common in early signs include coughing, chest pain, and hemoptysisTuberculosis- Caused by Mycobacterium tuberculosis - Transmitted by inhalation of infected droplets aerosolized in the air from the cough or sneeze of an infected person - Symptoms Night sweats, a typical pneumonia, low-grade fever, nonproductive coughing, hemoptysis, anorexia, and weight loss - PPD to test and if positive chest radiography within 72 hours - For older adults additional tests include CBC count, a erythrocyte sedimentation rate, chemistry panel, sputum test for AFB performed three times, and bone marrow biopsy. - Monitoring of the liver function on a monthly basis is recommended because older adults are at greater risk of developing hepatitis - Negative pressure room with door closed - IZONIAZID - 6 to 9 months in conjunction with other antituberculosis medication - RIFAMPIN - Monitor hepatic, renal, And hemolytic parameters. Give 1 hour before or 2 hours after meals. - May cause urine, stool, saliva, sputum, to turn red or orange and may stain clothes or contact lensesCommunity acquired Pneumonia (CAP)- Is a lower respiratory tract infection that has an onset in the community always in the first 2 days of hospitalization - <48 hours - Fever, cough, sputum production, General feelings of fatigue and malaise, And shortness of breath - Older patients do not always exhibit fever and coughing but often have symptoms of dehydration, confusion, and the respiratory rate greater than 26 breaths per minute - streptococcus pneumoniae is the leading causeHealthcare associated pneumonia or hospital acquired pneumonia (HCAP)- New hospitalization >48 hours or longer after admission who was not found to be incubating at the time of admission - Patient who was hospitalized in an acute care facility - Patient who resided in a long-term care facility - Who received recent intravenous antibiotic therapy, therapy, or would care within a month of the current infection - Patient who was seen in a hemodialysis facilityVentilator associated pneumonia (VAP)Occurs more than 48 hours after endotracheal intubationNosocomial pneumoniaOlder adults have 3x higher risk because they are more likely to be in high-risk areas such as residential centers, hospitals, and extended care facilitiesViral pneumoniaIt is most often associated with the history of influenza A virusAspiration pneumonia- Older adults are especially prone to aspiration pneumonia because of decreased coughing and gagging reflexes. - Positioning, feeding, and the use of a feeding tube give them high-risk - Use of narcotic medications, alcohol, and sedativesSevere acute respiratory syndrome SARS- May be deadly to older adults - The patient's travel history of foreign travel is imperative - Detection of antibody to SARS coronavirus (CoV) drawn during the acute illness or 21 days after the onset of illness confirms the diagnosis - S/S: a symptomatic or temperature over 100.4°F, coughing, shortness of breath, dyspnea, or hypoxemia.Pulmonary edema (PE)- It is an abnormal increase in the amount of fluid in the alveoli and insterstitial spaces of the lungs and maybe a complication of many cardiac and lung diseases - Left ventricular failure is the most common form of PE - Cardiogenic PE is the most common form of PE and is caused by the increased capillary hydrostatic pressure that results from myocardial infarction, mitral stenosis, decreased myocardial contract ability, left ventricular failure, or fluid overload - The clinical presentation of acute cardiogenic PE includes acute shortness of breath; orthopnea; frothy, blood-tinged sputum; cyanosis; diaphoresis; and tachycardia - Noncardiogenic: results from a variety of noncardiac causes. ARDS, reexpansion PE, and neurogenic PEPulmonary emboli-It is a blockage of pulmonary arteries by of thrombus, fat, or air embolus. -Often in the older patient, the blockage is a result of a deep vein thrombosis -Occlusion of the lung with a large embolus causes pulmonary infarction, which results in necrosis of lung tissue - The embolus causes bronchial constriction, ventilation - perfusion mismatch, and hypoxia - The clinical presentation includes coughing, dyspnea at rest, hypotension, hypoxia, hemoptysis, tachycardia, anginal or pleuritic chest pain, decrease PaO2, and S3 or S4 Gallop. - Diagnosis is based on ventilation- perfusion lung scanning (VQ scan) or pulmonary angiography - Fast acting heparin is a drug of choice for treatment of PE - Subcutaneous sleep or intravenously - Thrombolytic therapy such as tissue plasminogen activator (TPA) is used in patients with extensive pulmonary emboli that exhibit unstable hemodynamics situations - Long term treatment for recurring pulmonary emboli is done with warfarin (Coumadin) and monitoring of their international normalized ratio (INR) with a goal range of 2.5 to 3.0. - In older adults, dehydration and immobility are leading causes. With A Long bone or a pelvic fracture, Secondary to falling, Fat emboli should be suspected. - Promote mobility as soon as medically possible. Use anti-embolic stockings and passive and active range of motion exercises Eliminate use of aspirin or NSAIDs (GI issues), Green leafy vegetables and be cautious of use of over-the-counter medications that potentiate the anticoagulation effect.