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2023 Chronic Respiratory Problems.pptx
1. Management of the patient with Chronic
Respiratory System Disorders
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2. Learning Objectives
• At the end of this session, learners will be able to:
– Define and identify causes/risk factors for asthma, TB,
& COPD patients.
– Describe pathophysiology and C/M for asthma, TB, &
COPD patients.
– Identify appropriate diagnostic methods and possible
differentials for asthma, TB, COPD.
– Manage the pt using medical and nursing approaches
– Discuss prevention methods for asthma, TB,& COPD
pts.
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3. Brainstorming
• Being in a group of FIVE and discuss the following
points:
– Definitions, causes/risk factors, pathophysiology,
C/M, diagnosis methods, DDX, Complications,
medical and nursing management, and prevention
methods for:
• Asthma, TB, COPD
–Discussion: Ten minutes
–Presentation: Five minutes
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5. Asthma
• Is a heterogeneous disease characterized by bronchial
hyper reactivity with reversible expiratory airflow
limitation.
• Affects around 20.4 million adult Americans.
• It is a major public health concern, with more than 1.7
million emergency department (ED) visits each year.
• Before puberty, more boys are affected than girls.
• In adulthood, women are much more likely to be affected
than men.
• Women who present to the ED are more likely to need
hospitalization than men.
• Mortality is higher in women than in men.
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12. Status Asthmaticus
• Life-threatening medical emergency, most extreme form of an
asthma attack.
• It is characterized by hypoxia, Hypercapnia, and acute
respiratory failure.
• The patient is unresponsive to treatment with bronchodilators
and corticosteroids.
• The patient may have chest tightness, a severely marked
increase in shortness of breath, or suddenly be unable to speak.
• Hypotension, bradycardia, and respiratory and/or cardiac arrest
may occur if we do not recognize that the patient’s condition is
getting worse.
• The patient must be immediately intubated, and mechanical
ventilation started.
• Hemodynamic monitoring of the patient is critical.
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13. Status Asthmaticus
• Analgesia and sedation are essential.
• Continuous analgesic infusions (e.g., ketamine, morphine)
and sedation with drugs such as propofol help decrease
work of breathing and facilitate patient synchrony with the
ventilator.
• Sometimes neuromuscular blocking agents may be used.
• Inhaled anesthetics, such as isoflurane or halothane, are an
option for those not responding to conventional
treatment.
• IV magnesium sulfate, which has a bronchodilator effect,
may be given to patients with a very low FEV1 (forced
expiratory volume in 1 second) or peak flow (less than 40%
of predicted or personal best) or those who do not
respond to initial treatment.
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15. Diagnostic studies
• Under diagnosis of asthma is common.
• A detailed history is important to determine if a
person has had similar attacks, which are often
precipitated by a known trigger.
• Because wheezing and cough occur with a variety of
disorders (e.g., COPD, GERD, vocal cord problems,
heart failure), it is important to determine if asthma
or some other disease process is the cause of these
problems.
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16. Diagnostic studies
• History and physical examination
• Spirometry, including response to bronchodilator
therapy
• Peak expiratory flow rate (PEFR)
• Chest x-ray
• Measurement of oximetry
• Allergy skin testing (if indicated)
• Blood level of eosinophils and IgE (if indicated)
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22. Nursing Interventions
• Health promotion
– Patient education
• Identify and avoid known personal triggers
–Dressing properly during cold weather
–Avoid exposure to pollens, dusts, known
irritants
–Timely treatment for URTI
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24. Tuberculosis
• Tuberculosis (TB) is an infectious disease commonly
caused by Mycobacterium tuberculosis.
• It usually involves the lungs, but can infect any organ,
including the brain, kidneys, and bones.
• About one third of the world’s population are
infected with TB.
• The incidence of TB worldwide declined until the
mid-1980s. We are now seeing increasing rates of TB.
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25. Tuberculosis
• This is attributed to HIV disease and the emergence of
drug-resistant strains of M. tuberculosis.
• TB is the leading cause of mortality in patients with HIV
infection.
• Immunosuppression from any cause (e.g., HIV infection,
cancer, long term corticosteroid use) increases the risk
for active TB infection.
• Once a strain of M. tuberculosis develops resistance to
the most potent first-line anti tubercular drugs
(isoniazidand rifampin), it is defined as MDR-TB.
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26. Vulnerable groups
• TB occurs disproportionately in the poor,
underserved, and minorities.
• People most at risk include the homeless, residents
of inner-city neighborhoods, foreign-born people,
those living or working in institutions (long-term care
facilities, prisons, shelters, hospitals), IV injecting
drug users, overcrowded living conditions, less than
optimal sanitation, and those with poor access to
health care.
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27. Epidemiology
• One third of world populations affected
• Globally, 10 million people fell ill in 2020 (5.6M men,
3.3M women, 1.1M children)
• Every year 1.5 M deaths occur because of TB
• Globally, 13th leading cause of death, and 2nd leading
infectious killer after COVID-19
• India followed by China were known to have high
disease burden
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28. Etiology and Pathophysiology
• M. tuberculosis is a gram-positive, aerobic, AFB.
• It is usually spread from person to person by airborne
droplets expectorated when breathing, talking, singing,
sneezing, and coughing.
• A process of evaporation leaves small droplet nuclei, 1 to 5
µm in size, suspended in the air for minutes to hours.
• Another person then inhales the bacteria.
• Humans are the only known reservoir for TB.
• TB is not highly infectious, as transmission usually requires
close contact and frequent or prolonged exposure.
• The disease cannot be spread by touching, sharing food
utensils, kissing, or any other type of physical contact and
in case if happens, it is minimal.
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29. Etiology and Pathophysiology
• Factors that influence transmission include:
– Number of organisms expelled into the air
– Concentration of organisms (small spaces with
limited ventilation would mean higher
concentration)
– Length of time of exposure, and
– Immune system of the exposed person
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30. Etiology and Pathophysiology
• Once inhaled, these small droplets lodge in
bronchioles and alveoli.
• A local inflammatory reaction occurs, and the focus of
infection is established which is called the Ghon lesion
or focus.
• It represents a calcified TB granuloma, the hallmark of
a primary TB infection.
• The formation of a granuloma is a defense mechanism
aimed at walling off the infection and preventing
further spread.
• Replication of the bacillus is inhibited, and the
infection is stopped. 30
33. Etiology and Pathophysiology
• Most immunocompetent adults infected with TB can
completely kill the mycobacteria.
• Some people have the mycobacteria in a non replicating
dormant state.
• Of these persons, 5% to 10% develop active TB infection
when the bacteria begin to multiply months or years later.
• While M. tuberculosis is aerophilic (O2 loving) and has an
affinity for the lungs, the infection can spread through the
lymphatic system and find favorable environments for
growth in other organs.
• These include the cerebral cortex, spine, epiphyses of the
bone, liver, kidneys, lymph nodes, and adrenal glands.
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34. Classifications of TB
Class 0 = No TB exposure
Class I = TB exposure, No infection
Class II = Latent TB infection, No disease
Class III = TB, Clinically active
Class IV = TB, But not clinically active
Class V = TB suspect (pending diagnosis)
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35. Classifications of TB
• Primary TB infection occurs when the bacteria are inhaled
and start an inflammatory reaction.
• Most people mount effective immune responses to
encapsulate these organisms for the rest of their lives,
preventing the initial infection from progressing to
disease.
• If the initial immune response is not adequate, the body
cannot contain the organisms.
• As a result, the bacteria replicate and active TB disease
results.
• When active disease develops within the first 2 years of
infection, it is called primary TB.
• People co-infected with HIV are at greatest risk for
developing active TB.
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36. Classifications of TB
• Post-primary TB, or reactivation TB, is defined as TB disease
occurring 2 or more years after the initial infection.
• If the site of TB is pulmonary or laryngeal, the person is
infectious and can transmit the disease to others.
• Latent TB infection (LTBI) occurs in a person who does not
have active TB disease.
• People with LTBI have a positive skin test but are
asymptomatic.
• They cannot transmit the TB bacteria to others but can develop
active TB disease at some point.
• Immunosuppression, diabetes, poor nutrition, aging,
pregnancy, stress, and chronic disease can reactivate the
disease.
• Treatment of LTBI is as important as primary TB.
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37. Clinical Manifestations
• S/SX of PTB usually do not develop until 2 to 3 weeks
after infection or reactivation.
• The primary manifestation is an initial dry cough that
often becomes productive with mucoid or
mucopurulent sputum.
• Active TB disease may initially present with
constitutional symptoms (e.g., fatigue, malaise,
anorexia, unexplained weight loss, low-grade fevers,
night sweats).
• Dyspnea is a late symptom that may signify
considerable pulmonary disease or a pleural effusion.
• Hemoptysis, which occurs in less than 10% of patients
with TB, is also a late symptom.
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38. Clinical Manifestations
• Sometimes TB has a more acute, sudden
presentation.
• The patient may have a high fever, chills, generalized
flu-like symptoms, pleuritic pain, a productive cough,
and acute respiratory failure.
• Auscultation of the lungs may be normal or reveal
adventitious sounds, such as crackles.
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39. Clinical Manifestations
• Immunosuppressed (e.g., HIV-infected) people and
older adults are less likely to have fever and other
signs of an infection.
• In patients with HIV, classic manifestations of TB, such
as fever, cough, and weight loss, may be wrongly
attributed to HIV-associated opportunistic diseases.
• Respiratory problems in patients with HIV must be
carefully investigated to determine the cause.
• A change in cognitive function may be the only initial
presenting sign of TB in an older person.
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41. Diagnostic Studies
• History and physical examination
• Tuberculin Skin Test
• The tuberculin skin test (TST) (Mantoux test) using
purified protein derivative (PPD) is the standard method
to screen people for M. tuberculosis.
• The test is given by injecting 0.1 mL of PPD intradermally
on the ventral surface of the forearm.
• The test is read by inspection and palpation 48 to 72
hours later for the presence or absence of induration.
• Induration, a palpable, raised, hardened area or swelling
(not redness) at the injection site means the person has
been exposed to TB and has developed antibodies.
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42. Diagnostic Studies
• Interferon-γ Release Assays
• Interferon-γ (INF-γ) release assays (IGRAs) are
another screening tool for TB.
• IGRAs are blood tests that detect INF-γ release from
T cells in response to M. tuberculosis.
• IGRAs offer several advantages over the TST in that
they require only 1 patient visit, are not subject to
reader bias, have no booster phenomenon, and are
not affected by prior BCG vaccination.
• Neither IGRAs nor TST can tell between LTBI and
active TB infection.
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43. Diagnostic Studies
• Chest X-ray
• Although the chest x-ray findings are important, it is
not possible to make a diagnosis of TB solely on
chest x-ray findings.
• The chest x-ray may appear normal in a patient with
TB.
• Findings suggestive of TB include upper lobe
infiltrates, cavitary infiltrates, lymph node
involvement, and pleural and/or pericardial effusion.
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44. Diagnostic Studies
• Bacteriologic Studies (sputum smear for AFB,
sputum culture)
• Culture is the gold standard for diagnosing TB.
• Three consecutive sputum specimens are needed,
each collected at 8- to 24-hour intervals, with at least
1 early morning specimen.
• The initial test involves a microscopic examination of
stained sputum smears for AFB.
• A definitive diagnosis of TB requires mycobacterial
growth, which can take up to 6 weeks.
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56. Management
• Sensitivity testing guides the treatment for MDR-TB.
• MDR-TB therapy in the initial phase typically includes
5 drugs: 1or 2 first-line agents, a fluoroquinolone, an
injectable antibiotic, and 1 or more second-line
agents, for at least 6 months after sputum culture is
negative.
• This is followed by at least 4 drugs, minus the
injectable antibiotic, for 18 to 24 months.
• Two newer drugs, bedaquiline and Delamanid, are
used in combination with other drugs to treat MDR-
TB and XDR-TB.
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57. Management
• Directly observed therapy (DOT) involves providing the anti
tubercular drugs directly to patients and watching as they
swallow the medications.
• To ensure adherence, it is the preferred strategy for all patients
with TB, especially for those at risk for non adherence.
• Non adherence is a major factor in the emergence of MDR-TB
and treatment failures.
• Many people do not adhere to the treatment program despite
understanding the disease process and value of treatment.
• DOT is an expensive but essential public health measure.
• The risk for reactivation of TB and MDR-TB is increased in
patients who do not complete the full course of therapy.
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58. Management
• In people with LTBI, drug therapy helps prevent a TB
infection from developing into active TB disease.
• Because a person with LTBI has fewer bacteria,
treatment is much easier.
• Usually only 1 drug is needed.
• The standard treatment regimen for LTBI is 9 months of
daily isoniazid.
• It is an effective and inexpensive drug that the patient
can take orally.
• While the 9-month regimen is more effective, adherence
issues may make a 6-month regimen preferable.
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59. Common Nursing Diagnoses
• Impaired breathing
• Impaired airway clearance
• Risk for infection
• Lack of knowledge
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60. Planning
• The overall goals are that the patient with TB will:
– Have normal pulmonary function,
– Adhere to the therapeutic regimen,
– Take appropriate measures to prevent the spread
of the disease,
– Have no recurrence of disease.
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61. Nursing Intervention
• Health education:
– DOT: Eradicating the bacteria
– Treatment adherence
– Avoiding overcrowdings
– Home ventilation
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62. Evaluation
• The expected outcomes are that the patient with TB
will have:
– Resolution of the disease
– Normal pulmonary function
– Absence of any complications
– No further transmission of TB
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