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1. 1
Unit II. Disorders of respiratory system
By Zebenay.W (MSc in Child health)
Contact Address:
zedo2015@gmail.com

2. Respiratory System
 Its primary function is delivery of oxygen to the
lungs and removal of carbon dioxide from the
lungs.
2

3. Thoracic Cavity
 The inside of the chest cage is called the thoracic
cavity.
 Contained within the thoracic cavity are the lungs,
cone-shaped, porous organs encased in the
pleura, a thin, transparent double-layered serous
membrane lining the thoracic cavity.
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4. The Anatomy of the Lungs
 The right lung is larger than the left and is divided
into three sections or lobes: upper, middle, and
lower.
 The left lung is divided into two lobes: upper and
lower.
 The upper portion of the lungs is the apex; the
lower portion is the base.
4

5. Conducting Airways
 The conducting airways are tubelike structures
that provide a passageway for air as it travels to
the lungs.
 The conducting airways include the nasal
passages, mouth, pharynx, larynx, trachea,
bronchi, and bronchioles.
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6. Pharynx Larynx Trachea
 The conducting airways that connect nasal passages
and mouth to the lower parts of the respiratory tract.
 The passageway for air entering and leaving the
trachea and containing the vocal cords.
 Commonly known as the windpipe, this tube is
composed of connective tissue mucosa and smooth
muscle supported by C-shaped rings of cartilage.
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7. Bronchi, Bronchioles
 Two tubes, the right and left primary bronchi, that each
pass into its respective lung.
 Within the lungs, the bronchi branch off into
increasingly smaller diameter tubes until they become
the terminal bronchioles.
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8. Respiration
 A process of gas exchange necessary to supply
cells with oxygen for carrying on metabolism, and
to remove carbon dioxide produced as a waste
by-product.
 Two types of respiration: external and internal.
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9. External & Internal Respiration
 The exchange of gases between the inhaled air
and the blood in the pulmonary capillaries.
 The exchange of gases at the cellular level
between tissue cells and blood in systemic
capillaries.
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10. Signs & Symptoms
1. Dyspnia
2. Cough
3. Sputum Production
4. Chest Pain
5. Wheezing
6. Hemoptesis
10

11. Assessment
Auscultation
(Listening for Normal and Adventitious Breath Sounds)
Palpation and Percussion
Inspection
(client's color, level of consciousness, emotional state)
(Rate, depth, quality, rhythm, effort relating to respiration)
Health History
(allergies, occupation, lifestyle, health habits)
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12. The Normal Breath Sounds
1.Vesicular breath sound that is characterized by:
 Inspiratory sounds lasting longer than expiratory
ones
 Soft and low pitched
 No pause between expiration and inspiration
 Heard through inspiration and one–third of
expiration
 Normally heard over most of both lungs
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13. 2.Bronchial Breath
sound that is characterized by:
 Loud and relatively high pitched
Expiratory sounds lasting longer than inspiratory
ones
 Short silent period between inspiration and
expiration
The normal location is over the manubrium if heard at
all
3.Broncho-Vesicular Breath
sounds are characterized by:
Intermediate in intensity and pitch
 Inspiratory and expiratory sounds are about equal in
duration
A silent gap between inspiration and expiration may or
may not be present
13

14. Adventitious Breath Sounds
 Fine crackles (dry, high-
pitched popping…COPD,
CHF, pneumonia)
 Coarse crackles (moist,
low-pitched
gurgling…pneumonia,
edema, bronchitis)
 Sonorous wheezes (low-
pitched snoring…asthma,
bronchitis, tumor)
 Sibilant wheezes (high-
pitched, musical …
asthma, bronchitis,
emphysema, tumor)
 Pleural friction rub
(creaking, granting…
pleurisy, tuberculosis,
abscess, pneumonia)
 Stridor (crowing…croup,
foreign body obstruction,
large airway tumor).
Abnormal sounds and some conditions associated
with them:
14

15. Terms
 Normal breathing (Eupnea): - A respiratory rate of 10- 20
breaths per minute
 Tachypnea: - Increased respiratory rate over 20 breaths per
minute
 Bradypnea: -Decreased respiratory rate under 10 breaths per
minute
 Apnea:- Total cessation of airflow to the lungs
 Hyperpnea:-Increase in depth of respiration
 Hyperventilation:-Increase in depth & rate of respiration
 Hypoventilation: slow or irregular respiratory pattern with
shallow respirations
 Hypoxia:- Situation in which there is lack of oxygen in the
body
 Hypoxemia:-Oxygen deficiency in the blood.
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16. Terms---
 Hypercapnia:-is the retention of co2 in the blood i.e. the PaCO2
> 45mmHg at rest
 Chyne-stokes respiration:- A cyclic pattern of progressively
deeper respirations , followed by progressively shallow
respirations, & a period of apnea
 e.g. CHF, drug over dose , renal failure
 Kussmal’s respiration: - Deep, regular, breaths, usually at a
rate greater than 20 per minute. E.g. DKA, renal failure,
metabolic acidosis states.
 Respiratory system:- a system in which gas exchange occurs.
(The air flows through nasal and or oral passage to the pharynx,
larynx, trachea, bronchi, bronchioles, and to the alveoli)
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17. Risk factors for respiratory disease
 Smoking - is the single most important contribution to lung
d/se
 Exposure to second hand smoke
 Personal or family history of lung disease
 Genetic make up
 Allergens and environmental pollutants
 Recreational and occupational exposure
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18. Assessment of the respiratory system
1/ HX
 Demographic data
 Personal & family Hx
 Occupational & socioeconomic status
 Common manifestations ( cough, sputum, dyspnea, chest pain
)
2/Physical examination
 V/S, HEENT, Digital clubbing
 Chest examinations(inspection, palpation, percussion &
auscultation)
 Breathing patterns
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19. Assessment of the respiratory system---
3/ Diagnostic assessments
 Laboratory tests(CBC, ABG, Thoracentesis)
 Imaging tests (Chest X-ray, CT, MRI)
 Non invasive tests ( Pulse oxymetry, PFTs)
 Invasive techniques (Bronhoscopy, laryngoscopy,
mediastinoscopy, thoracenthesis)
 Spirometry (TV, minute ventilation, VC,FEV1,FVC )
 Sputum tests
 Throat cultures
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20. 20

21. Upper respiratory tract disorders
Tonsillitis
Definition:- It is an inflammation & enlargement of the tonsil tissue
Causative agent:- Group A beta hemolytic streptococcus
- It can be viral in origin
- It is very common up to the age of 15 years
Predisposing factors:-
URTI, lowered immunity, pollution
Clinical features:- sore throat, dysphagia, headaches, earaches, voice
change & fever, snoring
Diagnostic evaluation
 History
 Physical examination / Enlarged hyperemic tonsils, tender and enlarged
cervical lymph nodes/
 Culture & sensitivity
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22. Nursing interventions:
-Analgesics such as paracetamol 500mg 2 tabs PRN
- Ampicillin/amoxacillin for 5-7 days
- Tepid sponge, high fluid intake,
- Bed rest and soft diet
- Warm saline gargles
Surgical mgt :- Tonsillectomy , Tonsiloadenectomy
Indications
- Recurrent tonsillitis not responding to antibiotic
- Obstruction to the airway
- Recurrent otitis media & hearing loss r/t tonsilitis
- After resolution of peritonsillar abscess
Complications
 Quinsy (Peritonsillar abscess)
 Laryngeal edema
 Acute otitis media, sinustis, deep neck abscess, pneumonia
 Septicemia, R-fever, RHD, acute nephritis
 Chronic tonsillitis
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23. Chronic tonsillitis
Def.;-It is due to recurrent acute tonsillitis attack.
Etiology: - similar to acute tonsillitis
C/M
- Recurrent pain - Cough - Enlarged cervical lymph node
R/X
- Nutritious diet & vitamins
- Antibiotic(Pencillins) & analgesics
- Tonsillectomy
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24. Peritonsillar abscess/ Quinsy/
It is a collection of pus outside the tonsillar capsule
- It is usually unilateral
Etiology:- streptococcus group A
Risk factors: - Age between 20 – 50 years
- Male affected more than females
- Foreign body embeded
C/M: - Pain, - swelling, - redness, trismus - salivation
- Malaise, fever, -rupture - Cervical lymphadenopathy
DDX: - acute tonsillitis , Retro-pharyngeal abscess
Complications
-Para-pharyngeal abscess ,septicemia & hemorrhage
RX :-
Antibiotic, oral hygiene,incision and drainage
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25. Pharyngitis
Defn :- It is a febrile inflammation of the throat
Causative agent:-
- Viral organism(adenoviruses,rhinoviruses)-70%
- Group A streptococcus is the most common bacterial organism
- Haemophilua influenza,staphylococus ,pneumococus
Clinical Features
 Red pharyngeal membrane & tonsil
 Enlarged & tender cervical lymph nodes
 Fever, malaise, & sore throat
 Odynophagia & dysphagia
 hoarseness,& cough
Diagnosis: - clinically (hyperemia & swelling of pharynx)
Differential diagnosis: -
- Tonsillitis - Laryngitis - Diphtheria
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26. Pharyngitis---
Complications
- Otitis media - mastoditis - meningitis
Medical Rx: - For bacterial causes
 Ampicillin 500mg po Qid for10 days or
 Erythromycin 500mg p.o. QID for 10days
Nursing interventions
 Instruct bed rest during febrile stage of illness.
 Liquid or soft diet is provided during acute stage of the disease.
 Warm saline gargles or irrigation are used. Irrigating the throat
properly is an effective means of reducing spasm in the pharyngeal
muscle.
 Acetaminophen 500mg 2 tabs at 6 hour interval.
 Mouth care can be given.
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27. Laryngitis
 It is an inflammation of the larynx often occurs as a result
of voice abuse, exposure to dust, chemicals, smoke, &
other pollutant.
Etiology: - Almost always virus - Bacterial invasion may
be secondary.
Risk factors: - URTI
 Vocal misuse and over use , Irritation / smoking, alcohol /
 Seasonal changes
 Iatrogenic / intubations and endo-laryngeal surgery /
 Laryngitis is usually associated with acute rhinitis or
naso-pharyngitis. It is common in winter & is easily
transmitted.
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28. Laryngitis---
C/F:- Hoarseness or complete loss of voice (aphonia)&
severe cough
 Pain occurs in severe cases
 Stridor may be present in children
 Edema, exudates, congestion
 Laryngitis can be the complication of chronic sinusitis & chronic
bronchitis.
Management
 Resting the voice, avoid smoking, bed rest
 Inhaling cool steam or aerosol
 Treat secondary bacterial infection with antibiotics
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29. Laryngitis---
Potential complications
 Sepsis, peritonsillar abscess, otitis media, sinusitis
Nursing interventions
 Clearing airway
 Humidifying the environment /inhaling steam/
 Promote comfort measures
- Give analgesics / acetaminophen . . . /
 Promoting communication
 Encourage voice rest
 Encouraging fluid intake
 Patient teaching – treatment regimen, prevention
 Monitor & Manage potential complication
29

30. Sinusitis
Is an inflammation of one or more sinuses. It occurs when infected
fluid/pus accumulates in the sinus
Causes
Allergy or virus
Bacteria (strep. Pneumoniae ,H.influenza,staphy,etc)
Maxillary & frontal sinuses are more affected
Predisposing factors
Nasal polyps & tumors
Deviated nasal septum
Facial trauma, dental infections
Chronically inhaled pollutants
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31. Sinusitis---
S&sxs
 Pain and sensation of pressure over the face
 Tenderness
 Nasal swelling and congestion
 Ear pain and swelling & headache
 Low grade fever
 Purulent/bloody nasal discharge
 Cough may be present
DX
HX & P/E-tenderness on percussion over the affected sinus
Paranasal sinus X-ray- Opacification & fluid
Coronal CT scanning/MRI- in chronic cases
31

32. Sinusitis---
Complications
 Cellulitis
 Osteomyelitis & bone destruction of the facial bones
 Meningitis, brain abscess or epidural abscess
 Ischemic infarction
Treatment & nursing interventions
Nasal decongestant (Oxymetazoline 0.05 %)
Anti allergic drugs and/or analgesics
Antibiotics amoxacillin 500 mg TID x 7ds
Hot application over the sinus
Nasal saline irrigation
Encourage high fluid intake
Surgery (Antral irrigation or endoscopic sinus surgery)
32

33. Lower respiratory tract disorders
Acute tracheo-bronchitis
Def: - Acute tracheobronchitis is an acute inflammation of the mucous mebranes
of the trachea & the bronchial tree that often follows infections of the upper
respiratory tract.
Causative agents
- It is often virus but the common bacterial causes are:- Streptococcus
pneumaniae, Haemephilus Influenza, Mycoplasma pneumonia
Predisposing factors
 Pre- existing URTI
 Inhalation of physical & chemical irritants gases & other air contaminants
Clinical manifestations
 Initially, that patient has a dry, irritating cough & expectorates scanty
sputum
 Sternal soreness from coughing
 Fever, headache, & generalized malaise
 As the infection progresses, inspiration may became noisy (inspiratory stridor)
& purulent sputum may be present.
33

34. Acute tracheo-bronchitis---
Medical management
Advice bed rest, steam inhalation
 Advice fluid intake to thin the viscous & tenacious secretions
 Dextromethorphan hydro-bromide 15-30mg P.O 3 to 4 times a day.
 Codeine phosphate 10 – 20 mg P.O. 3-4 times a day
Antibiotic treatment
 It is indicated, when bronchitis is complicated by bacterial infections
First line antibiotics
* Ampicillin 500mg P.O Qid, OR * Amoxicillin 500gm P.O tid, for 7 days
Alternative antibiotic
 Erythromycin 500mg P.O Qid for 7 days OR
 Tetracycline 500mg Qid, for 5-7 days OR
 Co - trimoxazole 480 mg 2 tabs po bid for 7 days
Nursing interventions
- Encourage frequent coughing to remove secretions
- Advice the patient bed rest, steam inhalation & increase fluid intake
34

35. Chronic bronchitis
Def: - It is the presence of a productive cough that lasts 3 months a year for
two consecutive years, in the absence of major lung disease (WHO)
 The accumulated secretions in the bronchioles interfere with effective
breathing
Causes: - The major causes are:-
 Cigarette smoking
 Exposure to pollution
 Patients with chronic bronchitis are more susceptible to recurring infections
of the lower respiratory tract
 Chronic bronchitis occurs mostly during the winter
Clinical manifestations
 A chronic, productive cough in the winter months (recurrent coughing and
sputum production)
 History of cigarette smoking & frequent respiratory infection
 Production of thick, gelatinous sputum ( greater amount’s produced during
super imposed infection)
 Wheezing and dyspnea as disease progresses
 Recurrent acute respiratory infections followed by persistent cough
35

36. Chronic bronchitis---
Diagnostic evaluation
* A complete history, including family, environmental exposure to
irritating substance, & occupational history, and also history of
smoking (number of packs per day)
* Physical examination
* Chest x-ray
* Lung function studies
* Arterial blood gas analysis
Medical management
 Remove bronchial secretions
 Bronchodilators are prescribed to relieve bronchospasm & reduce air
way obstruction
 Postural drainage
 Increase fluid intake
 The patient must stop smoking
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37. Bronchiectasis
Def:- Bronchiectasis is a chronic, abnormal & permanent dilatation of
the bronchi and bronchioles
Pathology
The dilatation is due to destructive & inflammatory changes in the wall
of medium-sized air ways. The normal components of the wall,
including cartilage, muscle, & elastic tissue, are destroyed & may be
replaced by fibrous tissue. The dilated airways frequently contains
thick, purulent materials, while peripheral airways are often occluded
by secretion or obliterated& replaced by fibrous tissue.
Causes
- Pulmonary infections
- Obstruction of the bronchus
- Aspiration of foreign bodies & vomitus
- Pressure from tumors, dilated blood vessels & enlarged lymph nodes.
37

38. Bronchiectasis---
Predisposing factors
* Infection in early child hood (measles, influenza, tuberculosis, &
immune deficiency disorders )
* Surgery (when patient is unable to cough)
* Infection
Damage bronchia wall

Thick sputum production

Sputum obstruct bronchi

Wall of bronchi will be distended by cough

Distended air way
* S.aureus & Klebsiella & anaerobes remain important causes of
bronchiectasis when antibiotic treatment of pneumonia is not given
38

39. Bronchiectasis---
C/M: - Chronic cough (persistent or recurrent)
- Copious amount of purulent sputum
- Haemoptysis (50-70%)
- Clubbing of the fingers
P/E: Crackles, rhonchi,& wheezes may be heard
Diagnosis: - Bronchography & bronchoscope & CT Scan
Medical management
 Antibiotic based on the results of culture & sensitivity
 Postural drainage
 Bronchodilators may be given
Surgical interventions
- Segmental resections - remove a segment of a lobe
- Lobectomy - remove lobe
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40. Atelectasis
Defn It is collapse of an alveolus, a lobule, or larger lung units
Causes: - Obstruction of a branches by foreign body, a plug of
thick exudates, or hypoventilation
Risk factors
 Splinting of the chest due to pain
 Respiratory depression from opioids, sedatives, & muscle
relaxants & abdominal distention
 Post operative patients, bedridden patients, pleural effusion,
pneumothorax,etc
40

41. Atelectasis---
C/M
- Marked dyspnea - Cyanosis( mainly central) - Pleural pain -
Tachycardia - Fever
- Signs of pulmonary infection may present
Medical mgt
 Aspirate the plural effusion & pneumothorax
 Mechanical ventilation may be necessary
 Remove the causes & risk factors
Preventions
 Encouraging the patient to cough, aspirate secretion, & postural
drainage
 Turn the patient frequently
 Coughing & deep breathing exercise postoperative
41

42. Pneumonia
 Pneumonia is an inflammatory process of the lung parenchyma that
is commonly caused by infectious agent
 Pneumonia is the most common cause of death
Classifications of pneumonia
There are three classification methods:-
* Etiological * Radiological * Clinical
Etiologic classifications
Infections - are the most common & most important
1/ Bacteria
a) Aerobic bacteria
Gram positive Gram negative
- Streptoccocus - E. coli
pneumoniae - Klebsiella
- Staphylococcus aureus - Pseudomonas
b) Anaerobic bacteria
2/ Virus 3/ Chlamydias 4/ Mycoplasmas 5/ Riketesiae
42

43. Pneumonia---
Radiologic /anatomic/ classification
1/ Lobar pneumonia
- If a substantial portion of one or more lobes is involved
2/ Broncho pneumonia
 It is distributed in a fashion, having originated in one or more
localized areas with in the bronchi & extending to the adjacent
surrounding lung parenchyma
 It is more common than lobar pneumonia
III) Clinical classifications
 Community acquired pneumonia / CAP/
 Hospital acquired pneumonia / Nosocomial/
 Aspiration pneumonia
 Pneumonia in immuno compromised individuals(PCP)
43

44. Community Acquired Pneumonia / CAP/
 Occurs either in community setting or within the
first 48 hrs of hospitalization
 Most common in people younger than 60 yrs
 Most prevalent during winter & spring
Causative agents are: -
 Typical or bacteria pneumonia
 Streptococcus pneumonia / 50 – 60% /
 Staphylococcus aureus
 H. influenzae
 Atypical pneumonia / 20%/
 Ricketesia
 Chlamydia
 Mycoplasmas
 Fungus
44

45. Hospital acquired pneumonia /Nosocomial/
Causative agents: -
Staph. auerus
Pseudomonas spp.
Gram negative enteric bacilli / E. col/, Klebsiella
 If admitted patient developed pneumonia after 48 hour of
admission, it is most likely nosocomial
45

46. Clinical Manifestations
 Sudden onset of shaking chills
 Rapidly increase in body temperature 38-40 C
 Chest pluratic pain increased by deep breathing
 Patient looks severely ill with marked tachypnea
 Shortness of breath
 Orthopnea
 Poor appetite
 Diaphoresis &tires easily
 Purulent sputum
46

47. Aspiration pneumonia
 Predisposing factors for aspiration pneumonia are:
 Coma / unconsciousness _ Seizure
 Causative agents: - most of them are normal flora of oropharynx
 They are anaerobic oral spp.
 They can cause necrosis of lung / SUPPURATION/ as a result they
cause lung abscess
 Clinical features: - Mimic pul. Tbc.
 Fever, chillness
 Weight loss
 Pleuritic chest pain
 Blood streaked sputum
47

48. Pneumonia in immuno compromised patients
Causative agents: -
Opportunistic / 50%/
 Pneumocystic carinii pneumonia / PCP / = Pneoumocystosis
 Pneumocystic Jirovecii pneumonia is a fungal infection of the lungs
 Cytomegala virus / CMV /
Bacterial : - those mentioned
Clinical features:-
 Cough : - first dry then rusty sputum / purulent/ after 24 hours
 Fever
 Pleurtic chest pain / aggravated by inspiration /
 Tachycardia
 Bronchial breath sound, dullness & some times crepitating
DX: - WBC & differential count - Sputum gram stain - Chest x – ray
Markers of severe pneumonia
 Respiration rate greater than 30/ min / adult/
 Cyanosis
 Hypotension
 Confusion age > 60 years
 If more than or equal to two lobe is involved
 Co – morbidity / asthma, DM. /
48

49. patient---
Complications
 Para-pneumonic effusion - Empyema - Lung abscess
 Lobar collapse - Sepsis
General management: -
 Analgesics for pain
 O2 administration
Specific management: -
 For community acquired pneumonia / CAP/
RX: - Amoxicillin 500mg po. Tid 7 days OR
- Ampicillin 500mg po. Qid for 7 days
 For severe CAP
 Admit the patient
 Crystalline penicillin 150,000 – 250.000 iu/ kg/ 24 hours, divided in to 6 doses.
 For atypical pneumonia MX:-
 Erythromycin 500mg p.o Qid for 7 days OR
 Tetracycline 500mg po Qid for 7 days.
** Erythromycin covers all causes of CAP
49

50. Hospital acquired pneumonia
*For gram negative bacteria: - Gentamycin 80mg iv / im tid
for 7 – 10 days
* For gram positive bacteria (s.aureus): - cloxacillin 500mg
po / iv qid for 7 – 10 days
Aspiration pneumonia
 Metronidazole 500mg po tid
 Amoxicillin 500mg po / iv tid
Pneumonia in immuno - compromised
 Pneumocystic Carnii Pneumonia / PCP/
*C/M of PCP includes:-
 Shortness of breath / SOB/ - Dry cough - Fever
P/E: - Marked tachypnea & cyanosis
- Chest finding are minimal
RX:- Co – trimoxazole 480mg 4 tabs tid for 21 days
50

51. Lung abscess
Defn : It is a localized necrotic lesion of the lung parenchyma containing
purulent material, the lesion collapses & forms a cavity.
Causes :
 Staphylococcus auerus: - is the most common aerobic organism.
 Anaerobic organisms are much more prevalent
Risk factors:
 Aspiration
 Mechanical / functional obstruction of bronchi by tumor, foreign body, or
bronchial stenosis
 Tuberculosis, chest trauma, necrotizing pneumonia, pulmonary embolism
C/M:-
 Fever
 Productive cough of moderate to copious amounts of foul – smelling sputum
 Pleurisy, chest pain, dyspnea, weakness anorexia, weight loss
DX: - History
- Dullness on percussion & decreased or absent breath sounds
P/E :-
 Crepitation , Chest x – ray, bronchoscope
 Sputum culture
51

52. Lung abscess---
Medical MX: - Admit the patient
 Cloxacillin 500mg IV Qid & change to po after 3 to 4 days
 Postural drainage & chest physiotherapy
 High protein & caloric diet
 Duration of antibiotic is for 6 weeks
 Surgical intervention is rare.
Preventions
 Appropriate antibiotic therapy before any dental procedure
 Oral hygiene
 Appropriate treatment of pneumonia
Nursing interventions
 Administer drugs as prescribed & monitor for any adverse effects.
 Chest physiotherapy
 Deep breathing & coughing exercise
 Proper nutrition /high protein & calories diet/ intake encouragement.
 Emotional support
 Mouth care
52

53. Pulmonary emphysema
Defn: - It is an abnormal distention of the air spaces beyond the terminal
bronchioles with destruction of the wall of the alveoli & finally lung
losses its elasticity, or
- A complex and destructive lung disease wherein air
accumulates in the tissues of the lungs.
 It is the end stage of a process that has progressed slowly for many
years
 It is irreversible problem
Predisposing causes: -
 Cigarette smoking ,air pollution, infection
C/M : - Onset is insidious, dyspnea, wheezing, tachypnea, anorexia,
weight loss, & weakness
 Patient usually has a history of cigarette smoking and history of chronic cough
 The symptoms are exacerbated with a respiratory infection
 Barrel chest & hyper resonant on percussion, decreased breath sound with ronchi
53

54. Pulmonary emphysema---
DX: - History & physical examination - chest x - ray
Management
 Bronchodilator:- given to dilate air way & these medications
include:
 Aminophylline, 5mg/kg by slow i.v push over 5 minutes
 Theophedrine (6mg/kg) 1 tab po tid
 Salbutamol aerosol inhalation 2 puffs TID/QID
 Treatment of infection
 Patients with emphysema are susceptible to lung infections & must
be treated at the earliest signs of infection. The most common
organisms are S.pneumonia & H. influenza.
 Ampicillin 500mg po Qid for 7 – 10 days OR
 Amoxicillin 500mg po Tid for 7 – 10 days OR
 CO – trimoxazole 960mg po bid for 7 days
 Administer oxygen
54

55. Bronchial asthma
Defn: - It is an intermittent, reversible, obstructive air way disease in which the
trachea & bronchi respond in a hyperactive way to certain stimuli.
 Airway hyper-responsiveness is defined as the exaggerated ability of the airways to
narrow in response to a variety of stimuli
 Asthma is a chronic inflammatory disorder of the airways in which many cells and
cellular elements play a role in particular, mast cells, eosinophils, T lymphocytes,
macrophages, neutrophils, and epithelial cells
 Asthma differ from COPD in that it is reversible process either
spontaneously or with treatment
Types of asthma
 Allergic asthma
- It is caused by known allergen/ dust pollens, animals, dander, & food/
- Most of the allergens are airborne & seasonal
- Family history of allergies
- Post medical history of eczema
 Idiopathic or non allergic asthma
 It is not related to a specific allergens.
 Aggravating factors include common cold respiratory tract infections, exercise, emotions, &
environmental pollutants.
 Mixed asthma
 It is the most common form of asthma
 It has the characteristics of both allergic & idiopathic asthma
55

56. Bronchial asthma---
C/M - Cough - Dyspnea - Wheezing- most common C/Fs
 Personal & or family history of allergic disease
 cyanosis - diaphoresis - tachycardia - widened pulse
pressure
→ Hypoxemia
DX - Complete history & P/E
 Chest x – ray :- over inflated lung
 Sputum & blood study (IGE ) Tenacious, rubbery, & whitish
Treatment
I. Acute asthma attacks
- Administer concentrated oxygen by mask ( 6 liters/ min)
- Rehydrate the patient
Drugs Rx: –
I / Initial Mx:-
A/ First line
 Salbutamol 2 puffs & repeat after 20 minute for the first hour OR
 Aminophylline, 5mg/kg slow iv push over 5 minutes. The same dose could be repeated after 30
minutes
B/ Alternative Mx
- Adenaline, 1:1000, 0.5ml sc. Repeat after 30 minute to 1 hour if patient doesn’t respond.
- If response to initial therapy is poor, give the following
56

57. Bronchial asthma---
First line: -
 Aminophylline drip load dose 3-5 mg/kg in dextrose & water
over 20 minutes. Then maintenance dose 0.6mg/kg hour in 5%
D/W
Plus Hydrocortisone, i.v 200mg stat AND/ OR Prednisolone,
40 – 60mg po in divide dose immediately after hydrocortisone
for 5 – 7 days.
II ) RX of chronic asthma
Intermittent Asthma
First Line: - Salbutamol, inhalation 2 puffs, 3 times a week
Alternative: - Thephedrine1 tab 3 times per day
Persistent Asthma
First Line: - Salbutamol inhalation 2 puffs x 3 / day OR
Theophedrine 100mg tid Plus Beclomethasone inhalation puff
daily for two weeks OR -Prednisalone, 0.5mg, po/ day.
57

58. Asthma
 Prevention : allergic test to identify the substances
cause the symptoms and avoid it as possible
 Complications
1. Asthmaticus
2. Rib fracture
3. Pneumonia
4. Atelectases
58

59. Asthma
 Nursing Management
1. Immediate care based on severity of
symptoms
2. Assessment & Allergic History
3. Administer medication & observe patient
response
4. Antibiotics as prescribed for infection
5. Assist in intubations procedure if needed
6. Psychological support for patient & his family
59

60. Chronic Obstructive Pulmonary Disease /
COPD/
 Disease state in which air flow is obstructed by
emphysema or bronchitis or both
 The airway obstruction is usually progressive &
irreversible
 Include:- chronic bronchitis, bronchiectasis, emphysema,
& asthma
Goal:-
 Improvement in gas exchange
 Achievement of airway clearance
 Improvement in breathing pattern
 Independence in self – care activities
 Improvement in activity tolerance
 Compliance with therapeutic program & home care
60

61. Clinical Manifestations
 Cough
 Increase work of breathing
 Severe dyspnea that interfere with patient activity
61

62. Chronic Obstructive Pulmonary Disease /
COPD/---
Nursing interventions
 Administer bronchodilators as prescribed
 Administer oxygen
 Encourage fluid intake
 Deep breathing exercise
 Perform postural drainage
 Encourage patient to begin to self bath, dress, & walk
 Support patient in establishing a regular regimen of exercise
 Discuss with patient about drugs
Potential complications of COPD
 Atelectasis
 Pneumothorax
 Status asthmatics
 Pulmonary hypertension
62

63. -
According to NICE-British Thoracic Society
 Severe :- FEV1 < 30% predicted
 Moderate:- FEV1 30 – 49 % predictetd
 Mild air flow obstruction:-
FEV1 50 – 80% predicted
63

64. Pleurisy/Pleuritis
- It is an inflammation of both layers of the pleura or sac that encases
the lung.
C/M: - Severe, sharp, ‘’ knifelike’’ pain during inspiration
 Friction rub
 The pain may be localized or radiates to the shoulder / abdomen
Pleurisy may develop with: -
 Pneumonia, URTI, Tuberculosis
 Pulmonary embolism
Dx: - Chest X- rays
 Sputum examination
 Pleural fluid analysis/ pleural biopsy
Medical Mx: -
 Treat the underlying disease /pneumonia. . .
 Analgesics / Indometacin 25mg p.o tid for 1week
Nursing interventions
 Turn frequently on the affected side to splint the chest wall / this lessen the
stretching of the pleura/
 Emotional support & teaching
64

65. Empyema
 It is a collection of purulent liquid / pus/ in the pleural cavity
 It may occur if the lung abscess extends through pleural cavity
C/M: - Fever, anorexia, & weight loss
 Night sweating ,chest pain , dyspnea
Dx: - 1) History & physical examination
 On auscultation absence of breath sounds
 On percussion – dullness
 Chest x ray
 Pleural fluid analysis (AFB, staining, protein, glucose, LDH)
Medical Mx: -
 Thoracentesis: - if fluid is not too thick
 Closed – chest drainage tube
 Antibiotic
Nursing interventions
 Resolution of empyema is prolonged process
 Instruct breathing exercises
 Provide care specific to drainage of pleural fluid
65

66. Pneumothorax
 It is the accumulation of air in the pleural space occurring
spontaneously from injury or disease
 In patients with chest trauma it is usually the result of a laceration
to the lung parenchyma, tracheo-bronchial tree or esophagus
 Patient’s clinical status depends on the rate of air leakage and size
of wound and on previous respiratory condition
1. Tension pneumothorax: - occurs when air is drawn in to the pleural
space from a lacerated lung or through a small hole in the chest wall
 Tension / pressure/ is built up with in the pleural space, which
caused the lung to collapse & the heart, great vessels, & trachea
shift toward unaffected parts
 Impairs respiratory & circulatory function
 Air enters but cannot leave
66

67. Pneumothorax---
Management
 Temporary decompression with syringe and needle inserted in to
second intercostals space
 Chest tube drainage of pleural space to evacuate air
2. Spontaneous pneumothorax
 These occurs in healthy individuals; is usually due to rupture of a sub
pleural bleb of the lung
 Treatment:- generally non-operative if pneumothorax is not too
extensive, needle aspiration or chest tube drainage may be necessary
 Surgical intervention (thoracotomy) for patents with recurrent
spontaneous pneumothorax
C/M: - Air hunger, hypotension, tachycardia, profuse
diaphoresis, cyanosis
Medical Mx: -
 Give o2
 Withdraw air by inserting needle over 2nd intercostals space
 Close the wound
67

68. Haemothorax
Defn: - Haemothorax is the accumulation of blood in the pleural
space.
Cause: - Trauma
C/M: - Dyspnea
 Chest tightness
 Haemoptysis
 Signs of hypovolemic shock
Diagnostic tests
 Chest x- ray
 Thoracentesis
 Bronchoscopy
Rx: - Chest tube is inserted to the fourth through sixth intercostals
space b/n posterior & anterior line of axilla to drain the blood
68

69. Pulmonary embolism
 Refers to the obstruction of one or more pulmonary arteries by a thrombus that
originates somewhere in the venous system or in the right side of the heart
Risk factors
 Venous stasis / slowing of blood flow in veins/ which may be due to:-
 Prolonged immobilization / post operative/
 Prolonged period of sitting
 Varicose veins
 Spinal cord injury
 Hypercoagulability / due to release of tissue thromboplastin often injury /
surgery/ due to:-
- Injury -Tumor - Increased platelet count
 Venous endothelial disease such as:- - Thrombophlebitis
 Certain disease states such as:-
- Trauma - Postoperative / postpartum period
 Other pre disposing factors include:-
- Pregnancy
- Oral contraceptive use
69

70. Pulmonary embolism---
C/M: - May be non specific
 Chest pain is the commonest symptom
 Dyspnea is the second most common symptom
 Tachypnea & Haemoptysis
 Tachycardia / rapid & weak pulse/
 Cough & diaphoresis
 Syncope & sudden death
** Multiple small emboli can lodge in the terminal pulmonary
arterioles, producing multiple small infarctions of the lungs
70

71. Pulmonary embolism---
Diagnostic evaluation :- Chest x – ray , Pulmonary angiography
Preventions:-
 Prevent deep vein thrombosis / active leg exercise to avoid venous
stasis, early ambulation, & use of elastic stockings /.
 Anticoagulant therapy
 Avoid leaving IV catheter in veins for prolonged periods.
 Elevate legs above level of heart
 Advice against habits that increase venous stasis such as: -
 Crossing leg
 Sitting or lying down for prolonged period
 Wearing constricting clothing
Emergency interventions
 Oxygen administration to relieve hypoxemia, respiratory distress, &
cyanosis
 Open IV infusion
 Catheterize to monitor urinary output
 IV diuretics
71

72. Pulmonary embolism---
Medical management
 Anticogulation therapy
 Heparin 5,000 units IV followed by continuous infusion of 1,000
unit per hour is used to prevent recurrence of emboli.
Surgical intervention
 Pulmonary embolectomy
Nursing interventions
 Prevention:- preventing thrombus formation / ambulation, active
& passive exercise to prevent venous stasis /
 Pain management
 Oxygen administration
 Patient education
 Coping with anxiety
72

73. Oxygen administration
 Oxygen therapy- is the administration of oxygen as a medical
intervention, which can be for a variety of purposes in both
chronic and acute patient care.
 Oxygen is essential for cell metabolism, and in turn, tissue
oxygenation is essential for all normal physiological functions
 Room air only contains 21% oxygen, and increasing the fraction
of oxygen in the breathing gas increases the amount of oxygen
in the blood
 High blood and tissue levels of oxygen can be helpful or
damaging, oxygen therapy should be used to benefit the patient
by increasing the supply of oxygen to the lungs and thereby
increasing the availability of oxygen to the body tissues,
especially when the patient is suffering from hypoxia and/or
hypoxaemia
73

74. Benefits of oxygen therapy
74

75. Benefits of oxygen therapy---
Additional benefits of oxygen therapy
 Increased clarity
 Relieves nausea
 Can prevent heart failure in people with severe lung disease
 Allows the bodies organs to carry out normal functions
Long-term benefits of oxygen therapy
 Prolongs life by reducing heart strain
 Decreases shortness of breath
 Makes exercise more tolerable
 Results in fewer days of hospitalization
75

76. Indications of oxygen therapy
 Oxygen is used as a medical treatment in both chronic and acute cases, and
can be used in hospital, pre-hospital or entirely out of hospital, dependant on
the needs of the patient and the views of the medical professional advising.
 In COPD (Chronic obstructive pulmonary disease) patients with PaO2 ≤
65mmHg or SaO2 ≤ 90 %.
 In emergency condition in resuscitation of major trauma, anaphylaxis, major
haemorrhage, shock, active convulsions ,Choking, cardiac arrest, foreign
inhalations ,carbon monoxide poisoning and hypothermia
 It may also be indicated for any other patient where their illness causes
hypoxaemia (Severe pneumonia, cardiac illness & asthmatic cases e.t.c)
 High concentration oxygen is used as home therapy to abort cluster headache
attacks, due to its vaso-constrictive effects
 Oxygen can be administered also in general anesthesia technique
 Indicated also as drug delivery route delivers nebulizable drugs such as
salbutamol or epinephrine into the airways by creating a vapor-mist from the
liquid form of the drug.
76

77. Indications for oxygen therapy---
Any individual with one or more of the following:
 Peri and post cardiac or respiratory arrest
 Hypoxia - diminished blood oxygen levels (oxygen
saturation levels of < 90%)
 Acute and chronic hypoxemia (PaO2 < 65mmHg, SaO2 < 90%)
 Signs and symptoms of shock
 Low cardiac output and metabolic acidosis (HCO3 < 18mmol/l)
 Chronic type two respiratory failure (hypoxia and hypercapnia)
77

78. Types of oxygen therapy
1. High concentration oxygen therapy – up to 60% results in the
reduced risk of hypoventilation and retention of carbon dioxide
 High concentration oxygen therapy can have detrimental effects
on the respiratory system, particularly after prolonged usage and
can lead to respiratory distress due to absorption atelectasis
(collapse of alveolus due to blockage)
 In the premature infant retrolental fibroplasias can be a side
effect due to vasoconstriction and could lead to permanent
blindness
78

79. Types of oxygen therapy---
2. Low concentration oxygen therapy (controlled oxygen
therapy) – used to correct hypoxaemia by using an accurate
amount of oxygen without depleting existing maintenance of
carbon dioxide and respiratory acidosis.
 Blood gases should be used to measure the precise
concentration of oxygen
3. Long term oxygen therapy (LTOT) – the provision of
continuous oxygen therapy for patients with chronic
hypoxaemia, requirements vary between 24 hour
dependency and dependency during periods of sleep.
79

80. Types of oxygen therapy---
Long Term Oxygen Therapy (LTOT)
 Principally aims to improve symptoms and prevent harm from
chronic hypoxaemia. Patient groups potentially affected by
chronic hypoxaemia include:
o Chronic lung disease
o Congenital heart disease with pulmonary hypertension
o Pulmonary hypertension secondary to respiratory disease
o Interstitial lung disease
o Obliterative bronchiolitis
o Cystic fibrosis and other causes of severe bronchiectasis
o Obstructive sleep apnea and other sleep related disorders
o Palliative care for symptom relief
80

81. Oxygen delivery systems
1. Nasal cannula
 Also called nasal prongs
 It is easy to apply and does not interfere with the client’s ability
to eat or talk
 It delivers a relatively low concentration of oxygen which is
24% - 45% at flow rates of 2 to 6 liters per minute.
81

82. Administering oxygen by nasal cannula
1. Explain procedure to patient and review safety precautions necessary
when oxygen is in use. Place “No Smoking” sign in appropriate
areas
2. Perform hand hygiene
3. Connect nasal cannula to oxygen setup with humidification, if one is
in use. Adjust flow rate as ordered by physician. Check the oxygen is
flowing out of prongs.
4. Place the prongs in patient’s nostrils. Adjust according to type of
equipment:
a/ Over and behind each ear with adjuster comfortably under
chin or b/ Around patient’s head
5. Use gauze pads at ear beneath tubing as necessary
6. Encourage patient to breathe through nose with mouth closed.
7. Perform hand hygiene
8. Assess and chart patient’s response to therapy
9. Remove and clean cannula and assess nares at least every 8 hours
82

83. 2. Face mask
 It cover the client’s nose and mouth
 Exhalation ports on the sides of the mask allow exhaled carbon
dioxide to escape
Types of face masks
 Simple Face Mask - Delivers oxygen concentrations from 40%
to 60% at liter flows of 5 to 8 liters per minute, respectively.
 Partial Rebreather Mask – Delivers oxygen concentration of
60% to 90% at liter flows of 6 to 10 liters per minute,
respectively
 Non Rebreather Mask – Delivers the highest oxygen
concentration possible 95% to 100% – by means other than
intubation or mechanical ventilation, at liter flows of 10 to 15
liters per minute
 Venturi Mask – Delivers oxygen concentrations varying from
24% to 40% or 50% at liter flows of 4 to 10 liters per minute
83

84. 84

85. Administering oxygen by mask
1. Explain procedure to patient and review safety precautions
necessary when oxygen is in use. Place No Smoking signs in
appropriate areas
2. Perform hand hygiene
3. Attach face mask to oxygen setup with humidification. Start
flow of oxygen to fill bag before placing mask over patient’s
nose and mouth
4. Position face mask over patient’s nose and mouth. Adjust it
with the elastic strap so mask fits snugly but comfortable on
face
5. Use gauze pads to reduce irrigation on patient’s ears and scalp
6. Perform hand hygiene
7. Remove mask and dry skin every 2 to 3 hours if oxygen is
running continuously. Do not powder around mask.
8. Assess and chart patient’s response to therapy
85

86. 3. Face Tent
 It can replace oxygen masks when masks are poorly
tolerated by clients
 It provides varying concentrations of oxygen such as 30% to
50% concentration of oxygen at 4 to 8 liters per minute
86

87. 4 . Transtracheal oxygen delivery
 It may be used for oxygen-dependent clients
 The client requires less oxygen (0.5 to 2 liters per minute)
because all of the low delivered enters the lungs
87

88. 5. Endotracheal tubes
 Tubes inserted to the trachea
 It provides oxygen up to 100 % at 2 to 6 liters per minute
Negative effects of oxygen therapy
 Heart damage
 Seizures
 Loss of respiratory drive
 Infant blindness
88

89. Oxygen therapy safety precautions
 Teach family members and roommates to smoke only outside or in provided
smoking rooms away from the client
 Place cautionary signs reading “No Smoking” Oxygen in use” on the clients
door, at the foot or head of the bed, and on the oxygen equipment
 Instruct the client and visitors about the hazard of smoking with oxygen use
 Make sure that electric devices (such as razors, hearing aids, radios,
televisions, and hearing pads) are in good working order to prevent the
occurrence of short-circuit sparks
 Avoids materials that generate static electricity, such as woolen blankets and
synthetic fabrics. Cotton blankets should be used , and client and caregivers
should be advised to wear cotton fabrics
 Avoid the use of volatile, flammable materials such as oils, greases, alcohol,
ether, and acetone(e.g. nail polish remover), near clients receiving oxygen
 Ground electric monitoring equipment, suction machines and portable
diagnostic machines
 Make known the location of the fire extinguishers, and make sure personnel
89

90. ANY
QUESTION?
90