Some Of The Censorious Disease Conditions And Management of Patient with Upper Respiratory And Lower Respiratory Tract Disorders

Introduction:

Disorders of the respiratory system are common and are encountered by doctors and nurses in every setting, from the community to the intensive care unit. Expert assessment skills must be developed and used to provide the best care for patients with acute and chronic respiratory problems. Alterations in respiratory status have been identified as important predictors of clinical deterioration in hospitalized patients. To differentiate between normal and abnormal assessment findings and recognize subtle changes that may negatively impact patient outcomes,doctors and nurses require an understanding of respiratory function and the significance of abnormal diagnostic test results.

1. COPD (Chronic Obstructive Pulmonary Disorder)

Conditions affecting the chest and lower respiratory tract range from acute problems to chronic disorders. COPD is serious and often life threatening. Excess secretion or mucus plugs may also cause Obstruction of airflow and result in COPD in an area of the lung. COPD also is observed in patients with a chronic airway obstruction that depends or blocks the flow of air to an area of the lung. Patient and family education is an important intervention in the management of all lower respiratory tract disorders.

Definition:

It includes several disorders that affect the movement of air in and out of the lungs. It includes mainly two important diseases : a) Chronic Obstructive bronchitis b) Emphysema

It occurs as a result of increased airway resistance secondary to bronchial mucosal edema or smooth muscle contraction.

Etiology and Risk factors :

• a) Smoking
• b) Chronic respiratory infections
• c) Hereditary and aging process

Chronic Obstructive Bronchitis

• It is inflammation of bronchi which causes increase mucus production and chronic cough.
• It is characterized by increased in the size and no of mucus glands, increase in no of goblet cells and Impaired ciliary function.
• These all changes results in increased susceptibility to infection it causes changes in bronchial walls which become inflamed and thickened. These all changes obstruct airways specially during expiration which ultimately leads to decreased alveolar ventilation. This is also known as ventilation – perfusion mismatch. ABG analysis shows increased PaCo2 and decreased PaO2. As a result polycythemia occurs.

Emphysema

Definition

It is a disorder in which the alveolar walls are destroyed which leads to permanent over distension of air spaces. It results in altered perfusion and difficult expiration can be seen in patient. It causes changes in the alveoli such as – a) Loss of elastic recoil, b) partial airway collapse. These results in formation of air pockets between the alveolar spaces and within the lung parenchyma. It is also known as dead space as it does not participate in exchange. c) Work of breathing increases because there is less functional lung tissue. It also destroyed Pulmonary capillaries which again decreases O2- perfusion.

Clinical Manifestation

1. Pursed – lip breathing
2. Cyanosis
3. Distended neck vein
4. Clubbing of digits
5. Productive Cough
6. Piting peripheral edema
7. Gait and walking corresponds to breathing ( frequent rest to breath)
8. Prolonged expiration
9. Dyspnea
10. Hemoptysis

Diagnostic Measures

1. History Collection
2. Physical Examination:
   • a) Inspection – Barrel Chest (Increased anterio posterior diametry).
   • b) Percussion – Hyper resonant sound.
   • c) Auscultation – Diminished breath sound, adventatious breath sound,hyperventilation.
3. Chest x- ray – Over inflation and flattered diaphragm
4. ECG- Interpretation
   • a) Enlarged heart
   • b) Signs of Cor – pulmonale(Right heart failure)
5. USG abdomen – Enlarged pulse rating liver

Complications

1. Respiratory infection
2. Cor – pulmonale ( Right heart failure)
3. Changes in brain function

Management

• Improved ventilation : Administerd bronchodialators or steroid.
• O2 therapy
• Remove bronchial secretion : Administerd nebulization, administered bronchodialators, postural drainage, chest physiotherapy.
• Promote breathing exercise – Diaphragmatic breathing, pursed – lip breathing
• Controlled Complications : Heart failure is controlled by Diuretics, and digitalist.
• Improve general health.

2. Atelectasis

Atelectasis refers to closure or collapse of alveoli and often is described in relation to chest x-ray findings and or clinical signs and symptoms. It is one of the most commonly encountered abnormalities seen on a chest x – ray. Atelectasis may be acute or chronic and may cover a broad range of pathophysiologic changes,from microatelectasis (which is not detectable on chest x- ray) to macroatelectasis with loss of segmental, lobar, or overall lung volume. The most commonly described atelectasis is acute atelectasis, which occurs most often in the postoperative setting or in people who are immobilised and have a shallow, monotonous breathing pattern.

Definition :

It is the collapse of alveoli or lung tissue.

Etiology and Risk Factors

• Chest wall disorders
• Impaired Diaphragmatic movement.
• Ex – obesity, ascites
• CNS dysfunction. Ex – coma, neuromuscular disorders, airway obstruction
• Insufficient Pulmonary surfactant. Ex – smoke, inhalation, expiration of gastric consents etc.

Pathophysiology :

Due to the causes the ability of the lungs to expand get affected. It results in complete deflection of the alveoli.

Clinical Manifestation :

• Dyspnea
• Tachypnea
• Tachycardia
• Cyanosis
• Low grade fever

Diagnostic Measures :

1. History Collection : History of smoking
2. Physical Examination :
   • a) Tracheal Shift
   • b) Full percussion
   • c) Decreased chest movement on the involved side.

Management :

• Early ambulation
• Position changes
• Deep breathing and effective coughing
• O2 administration
• Symptomatic management
• Mechanical ventilation

3. Pulmonary Embolism

Pulmonary Embolism to the 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. Deep vein thrombosis (DVT), a related condition, refers to thrombus formation in the deep veins, usually in the calf or thigh, but sometimes in the arm, especially in patients with peripherally inserted central catheters.

Pulmonary Embolism can be associated with trauma, surgery (orthopedic, major abdominal, pelvic, gynecologic), pregnancy, heart failure, age older than 50 years, hypercoagulable states, and prolonged immobility. It also may occur in apparently healthy people.

Definition :

It is the occlusion of a portion of the Pulmonary blood vessels by an embolus.

Etiology and Risk Factors :

• Deep vein thrombosis (Femoral, popliteal or iliac vein)
• Endocarditis
• Major operations (Hip, knee, abdomen and pelvic areas)
• Infections (presence of air, fat and bone marrow in the blood)

Pathophysiology :

Most commonly, Pulmonary Embolism is due to a blood clot or thrombus. However, there are other types of emboli : air, fat, amniotic fluid, and Septic ( from bacterial invasion of the thrombus). When a thrombus completely or partially obstructs a Pulmonary artery or its branches, the alveolar dead space is increased. The area, although continuing to be ventilated, receives little or no blood flow. Therefore, gas exchange is Impaired or no blood flow. Therefore, gas exchange is Impaired or absent in this area. In addition, various substances are released from the clot and surrounding area that cause regional blood vessels and bronchioles to constrict. This results in an increase in pulmonary vascular resistance – a reaction that compounds the V/Q imbalance.

The hemodynamic consequences are increased Pulmonary vascular resistance due to the regional vasoconstriction and reduced size of the Pulmonary vascular bed. This results in an increase in pulmonary arterial pressure and, in turn, an increase in right ventricular work to maintain Pulmonary blood flow. When the work requirements of the right ventricle exceed its capacity, right ventricular failure occurs, leading to a decrease in cardiac output followed by a decrease in systemic blood pressure and the development of shock. Arterial fibrillation can also cause Pulmonary Embolism. An enlarged right atrium in fibrillation causes blood to stagnate and form clots in this area. These clots are prone to travel into the Pulmonary circulation.

A massive Pulmonary Embolism is best defined by the degree of hemodynamic instability rather than the percentage of Pulmonary vasculature occlusion. It is described as an occlusion of the outflow tract of the main Pulmonary artery or of the bifurcation of the Pulmonary arteries. Multiple small emboli can lodge in the terminal Pulmonary arterioles, producing multiple small infarction of the lungs. A Pulmonary infarction causes ischemic necrosis of part of the lung.

Clinical Manifestation :

1. Dyspnea
2. Tachypnea
3. Anxiety
4. Chest pain
5. Cough
6. Hemoptysis
7. Diaphoresis
8. Syncope

Diagnostic Measures :

• History Collection
• Physical Examination
• Auscultation : Crackles, heart murmurs
• ABG analysis
• Blood studies ( Lipid profile)
• CT scan
• Pulmonary angiography

Management :

1. Stabilizing the cardio Pulmonary system :
   • a) Low flow O2
   • b) Administration of fluid (to treat hypotension)
   • c) Administer NaHCO3
   • d) Mechanical ventilation
2. Anticoagulant therapy : Heparin Na, continued with warfarin Na.
3. Fibrinolytic therapy (Streptokinase)
4. Symptomatic management

Surgical Management :

• Pulmonary embolectomy :Surgical removal of emboli from the Pulmonary arteries through thoracotomy.
• Venacava filter insertion

4. Pneumonia

Pneumonia is an inflammation of the lung parenchyma caused by various microorganisms, including bacteria, mycobacteria, fungi, and viruses. Pneumonitis is a more general term that describes an inflammatory process in the lung tissue that may predispose or place the patient at risk for microbial invasion.

Definition :

It is an inflammatory process in the lung parenchyma usually associated with a marked increased in intestatial and alveolar fluid.

Etiology :

Bacteria, virus, fungal agents, protozoa, aspiration of food, fluid or vomitus, inhalation of toxic gases or chemicals.

Risk Factors :

Advance age, history of smoking, upper respiratory infection, Tracheal intubation, prolonged immobility, immuno suppressive therapy, Malnutrition, dehydration, chronic diseases – eg: diabetes melitus, cancer, chronic lung disease etc.

Types of Pneumonia :

1. Segmental Pneumonia : One or more lobe segments of the lungs are involved.
2. Bilateral pneumonia : Lobes in both lungs are affected.
3. Lobar pneumonia : One or more entire lobes are affected.
4. Based on location at radiological appearance –
   • a) Bronchopneumonia : Involves the terminal bronchioles and alveoli.
   • b) Interstitial pneumonia : Inflammatory responses within lung tissue surrounding the air spaces.
   • c) Alveolar or necrotizing pneumonia : Fluid accumulation in the distal air spaces. It also causes the death of a portion of lung tissue surrounded by tissue.

Pathophysiology :

Clinical Manifestation :

• Fever and cough
• Cough
• Pleuritic chest pain
• Sputum production
• Hemoptysis
• Dyspnea
• Headache
• Fatigue

Diagnostic Measures :

1. History Collection
2. Physical Examination
   • a) Palpation :Increased tactile fremitus (usually increased over areas of pneumonia)
   • b) Percussion :Dull sound
   • c) Auscultation :Crackled sound
3. ABG analysis
4. Chest x-ray
5. Bronchoscopy : For confirmation

Management :

• Administration of antibiotics
• O2 therapy
• Administration of bronchodialators
• Postural drainage
• Chest physiotherapy
• Fluid and electrolyte management
• Tracheal succining
• Respiratory support (medical emergency)
• Nutritional support

5. Pulmonary Tuberculosis

Tuberculosis (TB) is an infectious disease that primarily affects the lung parenchyma. It also may be transmitted to other parts of the body, including the meninges, kidneys, bones, and lymph nodes. The primary infectious agent, M. tuberculosis, is an acid fast aerobic rod that grows slowly and is sensitive to heat and ultraviolet light. Mycobacterium bovis and Mycobacterium avium have rarely been associated with the development of a TB infection.

TB is a worldwide public health problem that is closely associated with poverty, Malnutrition, overcrowding, substandard housing, and inadequate health care. Mortality and morbidity rates continue to rise. M. tuberculosis infects an estimated one third of the world’s population and remains the leading cause of death from infectious disease in the world.

Definition :

It is a communicable disease caused by microbacterium tuberculi, air borne infection which results in changes in the lung parenchyma. This organism is also multi drug resistant which is extremely difficult to treat.

Risk Factors :

1. Immuno suppressed client
2. Low income population
3. IV drug uses
4. Health care workers
5. Residence of long term care facility

Pathophysiology :

1. Primary Infection :
   • a) First time when clients is infected with TB is said to be primary infection
   • b) It is usually located in the apices of the lungs or near the pleura of the lower lobes.
   • c) Primary infection are usually microscopic ( not appear on x-ray)
   • d) Changes include :
     • i) Bronchopneumonia develops
     • ii) Phagocytosis of the infecting tubercle bacilli by warmed ring macrophages.
     • iii) Before broadly defense mechanism many of the bacilli survive within blood cells and may be carried into regional bronchopulmonary lymph nodes through lymphatic system. That is the infection even though the small spread through out the body.
   • e) Primary infection side undergo a process of necrotic degeneration also known as caseation ( cavities filled with cheez like mass of tubercle bacilli, dead WBCs and necrotic lung tissue)
   • f) This material liquifies and may trained into the tracheobroncheal tree and may be coughed up. The airfilled cavities remain and may be detected on x-ray. Usually this heal over a period of months by forming scars and then become calcified lesions also known as ‘ghon tubercle’ ( It contain living bacilli that can be reactivate at cause secondary infection). Primary TB infection cause an allergic reaction to TB bacilli or their protein. This cell mediate immune response appears in the form of sensitized T cell and is detectable as positive reaction to a tuberculin skin test. (Tuberculin sensitivity occurs in all body cells 2-6 weeks after primary infection, which will not allow further growth of bacilli and prevent infection)
2. Secondary infection : It occurs when the clients immune resistance is lower. The reason behind active TB disease a still unknown. The people who developed active TB disease include – a) advance age, b) HIV infection, c) Immuno suppression, d) Prolonged corticosteroid therapy, e) Low body weight, f) Substance abuse, g) Chronic disease, h) genetic pre disposition.

Clinical Manifestation :

1. Productive or non – productive cough
2. Fatigue
3. Anorexia
4. Weight loss
5. Low grade fever
6. Dyspnea
7. Hemoptysis
8. Chills and sweat at night
9. Chest pain
10. Chest tightness

Diagnostic Measures :

• History Collection
• Physical Examination :In Auscultation Crackles sound is present
• Tuberculin skin test
• Chest x-ray
• AFB sputum smear examination
• CT scan

Management :

• It is long term process
• Clients with active TB are usually started on a minimum of 2-3 medication to eliminate the resistance organism.
• The drugs usually administered for tuberculosis include – a) Isoniazid acid b) Rifampicin, c) Pyrazinamide, d) Ethambutol.

Conclusion :

Doctors, nurses and other medical stuff involvement in a general respiratory assessment includes a variety of interventions. The nurse must obtain specific history data , including information about smoking history and other environmental hazards. The physical examination includes the assessment techniques of inspection,palpation, percussion and auscultation.

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– Posted By Anita Ghosh