Nursing management of patient with Respiratory DO.pptx

4/10/2024
By Abdi Wakjira( Bsc, Msc)
1
NEKEMTE HEALTH
SCIENCE COLLEGE
Department of
Nursing
For Post Basic BSc Nursing
Students

Objectives
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 At the end of this chapter students will able to:-
Conduct the assessment of respiratory system
Air way patency care in respiratory system disorder
Describe upper respiratory system disorders and
their managements
Describe upper lower system disorders and their
managements

Respiratory systems disorder
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Anatomic and Physiologic Overview
The respiratory system is composed of the upper and lower
respiratory tracts.
Upper Respiratory Tract consist of the nose, sinuses and
nasal passages, pharynx, tonsils and adenoids, larynx, and
trachea. warms and filters inspired air.
Lower Respiratory Tract consists of the lungs, which
contain the bronchial and alveolar structures needed for gas
exchange. accomplish gas exchange.
Together, the two tracts are responsible for ventilation
(movement of air in and out of the airways).

Function of the Respiratory System
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Provides oxygen to the blood stream and
removes carbon dioxide
Enables sound production or vocalization as
expired air passes over the vocal chords
Enables protective and reflexive non-breathing air
movements such as coughing and sneezing, to
keep the air passages clear
Control of acid-base balance
Control of blood ph

Diagnostic procedures Of Respiratory systems
disorder
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Pulmonary Function Tests: used in patients with
chronic respiratory disorders.
Complete blood count. Measurement of red blood
cells and hemoglobin can give information about the
oxygen-carrying capacity of the blood.
Arterial Blood Gas Studies:- Measurements of blood
pH and of arterial oxygen and carbon dioxide tensions
 The arterial oxygen tension (PaO2) indicates the
degree of oxygenation of the blood.
 The arterial carbon dioxide tension (PaCO2) indicates
the adequacy of alveolar ventilation.

Diagnostic ….
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Sputum Studies used to:
 Identify pathogenic organisms
 Determine whether malignant cells are present.
 Assess for hypersensitivity states (in which there is an
increase in eosinophils).
Pulse Oximetry:-is a noninvasive method of continuously
monitoring the oxygen saturation of hemoglobin (SaO2).
Chest x-ray:_ ordered to help diagnose a variety of
pulmonary disorders.
Usually, posterior-anterior and side views (lateral) are taken.

Diagnostic….
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Computed Tomography is an imaging method in which
the lungs are scanned in successive layers by a narrow-
beam x-ray.
Bronchoscopy:- is the direct inspection and
examination of the larynx, trachea, and bronchi through
either a flexible fiberoptic bronchoscope or a rigid
bronchoscope.
Thoracoscopy:- is a diagnostic procedure in which the
pleural cavity is examined with an endoscope.
Thoracentesis (aspiration of fluid or air from the pleural
space) is performed for diagnostic or therapeutic reasons.

Chest Examination
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 Physical Examination. Vital signs,
including temperature, pulse, respirations,
blood pressure, and SpO2 (oxygen
saturation obtained by pulse oximetry), are
important data to collect before
examination of the respiratory system.

FOUR COMPONENTS OF A
RESPIRATORY ASSESSMENT
 INSPECTION
 PALPATION
 PERCUSSION
 AUSCULTATION

INSPECTION
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 Nose. Inspect the nose for patency,
inflammation, deformities, symmetry, and
discharge.
 Check each naris for air patency with
respiration while the other naris is briefly
occluded.
 Tilt the patient’s head backward and push
the tip of the nose upward gently. With a
nasal speculum and a good light, inspect
the interior of the nose.

Cont …d
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 Mouth and Pharynx. Using a good light source,
inspect the interior of the mouth for color, lesions,
masses, gum retraction, bleeding, and poor
dentition.
 Inspect the tongue for symmetry and lesions.
 Observe the pharynx by pressing a tongue blade
against the middle of the back of the tongue.
 A normal response (gagging) indicates that
cranial nerves IX (glossopharyngeal) and X
(vagus) are intact and that the airway is
protected

Cont ..d
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 Neck. Inspect the neck for symmetry and tender
or swollen areas.
 Palpate the lymph nodes while the patient is
sitting erect with the neck slightly flexed.
 Progression of palpation is from the nodes
around the ears, to the nodes at the base of the
skull, and then to those located under the angles
of the mandible to the midline.
 The patient may have small, mobile, nontender
nodes (shotty nodes), which are not a sign of a
pathologic condition.
 Tender, hard, or fixed nodes indicate disease.

Cont …d
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 Thorax and Lungs. Picture imaginary lines on the
chest to help identify abnormalities.
 Describe abnormalities in terms of their location
relative to these lines (e.g., 2 cm from the right mid
clavicular line).
 Chest examination is best performed in a well-
lighted, warm room with measures taken to ensure
the patient’s privacy.
 Perform all physical assessment maneuvers
(inspection, palpation, percussion, auscultation) on
either the anterior or the posterior chest rather than
moving from anterior to posterior or vice versa with
each maneuver.

Cont…d
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 Inspection- When inspecting the anterior chest,
have the patient sit upright or with the head of the
bed upright.
 The patient may need to lean forward for support on
the bedside table to facilitate breathing.
 First, observe the patient’s appearance and note any
evidence of respiratory distress, such as tachypnea
or use of accessory muscles.
 Next, determine the shape and symmetry of the
chest.

Inspection Cont ..d
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 Chest movement should be equal on both
sides, and the AP diameter should be less
than the side-to-side or transverse diameter
by a ratio of 1:2.
 An increase in AP diameter (e.g., barrel
chest) may be a normal aging change or
result from lung hyperinflation.
 Observe for abnormalities in the sternum
(e.g., pectus carinatum [a prominent
protrusion of the sternum] and pectus
excavatum [an indentation of the lower
sternum above the xiphoid process]).

Inspection Cont ..d
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 Next observe the respiratory rate, depth, and
rhythm.
 The normal rate is 12 to 20 breaths/minute; in
the older adult, it is 16 to 25 breaths/minute.
Inspiration (I) should take half as long as
expiration (E) (I:E ratio = 1:2).

Inspection Cont ..d
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 Observe for abnormal breathing patterns, such
as Kussmaul (rapid, deep breathing),
CheyneStokes (abnormal respirations
characterized by alternating periods of apnea
and deep, rapid breathing), or Biot’s (irregular
breathing with apnea every four to five cycles)
respirations.
 Skin color provides clues to respiratory status.
Cyanosis, a late sign of hypoxemia, is best
observed in a dark-skinned patient in the
conjunctivae, lips, and palms and under the
tongue.

Inspection Cont ..d
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 Inspect the fingers for evidence of long-
standing hypoxemia known as clubbing (an
increase in the angle between the base of
the nail and the fingernail to 180 degrees
or more, usually accompanied by an
increase in the depth, bulk, and
sponginess of the end of the finger)

Palpation
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 Palpation. Determine tracheal position by
gently placing the index fingers on either
side of the trachea just above the
suprasternal notch and gently pressing
backward. Normal tracheal position is
midline; deviation to the left or right is
abnormal.
 Tracheal deviation occurs away from the
side of a tension pneumothorax or a neck
mass, but toward the side of a
pneumonectomy or lobar atelectasis.

Palpation cont…d
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 Symmetry of chest expansion and extent of movement
are determined at the level of the diaphragm.
 Place your hands over the lower anterior chest wall
along the costal margin and move them inward until
the thumbs meet at midline.
 Ask the patient to breathe deeply.
 Observe the movement of the thumbs away from each
other. Normal expansion is 1 in (2.5 cm).
 Hand placement on the posterior side of the chest is at
the level of the tenth rib.
 Move the thumbs until they meet over the spine.
 Check expansion anteriorly or posteriorly, but it is
not necessary to check both.

Palpation cont…d
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 Normal chest movement is equal.
 Unequal expansion occurs when air entry is limited
by conditions involving the lung (e.g., atelectasis,
pneumothorax) or the chest wall (e.g., incisional
pain).
 Equal but diminished expansion occurs in conditions
that produce a hyperinflated or barrel chest or in
neuromuscular diseases (e.g., amyotrophic lateral
sclerosis, spinal cord lesions).
 Movement may be absent or unequal over a pleural
effusion, an atelectasis, or a pneumothorax.

Cont …d
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 Fremitus is the vibration of the chest wall
produced by vocalization.
 Tactile fremitus can be felt by placing the palmar
surface of the hands with hyperextended fingers
against the patient’s chest.
 Ask the patient to repeat a phrase such as
“ninety-nine” in a deeper, louder than normal
voice.
 Move your hands from side to side at the same
time from top to bottom on the patient’s chest.
 Fremitus is less intense farther away from these
areas

Fremitus Cont …d
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 When performing percussion, palpate all
areas of the chest and compare vibrations
from similar areas.
 Tactile fremitus is most intense adjacent to
the sternum and between the scapulae
because these areas are closest to the
major bronchi.
 Fremitus is less intense farther away from
these areas

Fremitus Cont …d
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 Increased fremitus occurs when the lung becomes
filled with fluid or is denser.
 As the patient’s voice moves through a dense tissue
or fluid, you can feel that the vibration is increased.
 This is found in pneumonia, in lung tumors, with
thick bronchial secretions, and above a pleural
effusion (the lung is compressed upward).
 Fremitus is decreased if the hand is farther from the
lung (e.g., pleural effusion) or the lung is
hyperinflated (e.g., barrel chest).Absent fremitus
may be noted with pneumothorax or atelectasis.

Percussion
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 Percussion. Percussion is performed to assess the
density or aeration of the lungs.
 The anterior chest is usually percussed with the patient
in a semi-sitting or supine position.
 Starting above the clavicles, percuss downward,
interspace by interspace
 The area over lung tissue should be resonant, with the
exception of the area of cardiac dullness.
 For percussion of the posterior chest, have the patient sit
leaning forward with arms folded.
 The posterior chest should be resonant over lung tissue
to the level of the diaphragm

Percussion Cont …d
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 Sound Description
Resonance Low-pitched sound heard over normal lungs
Hyperresonance
Loud, lower-pitched sound than normal
resonance heard over hyperinflated lungs,
such as in chronic obstructive pulmonary
disease and acute asthma
Tympany
Sound with drumlike, loud, empty quality
heard over gas-filled stomach or intestine, or
pneumothorax
Dull
Sound with medium-intensity pitch and
duration heard over areas of “mixed” solid
and lung tissue, such as over top area of
liver, partially consolidated lung tissue
(pneumonia), or fluid-filled pleural space
Flat
Soft, high-pitched sound of short duration
heard over very dense tissue where air is
not present, such as posterior chest below
level of diaphragm

Auscultation
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 Auscultation. During chest auscultation, instruct the
patient to breathe slowly and a little more deeply
than normal through the mouth.
 Auscultation should proceed from the lung apices to
the bases, comparing opposite areas of the chest,
unless the patient is in respiratory distress or will tire
easily; if so, start at the bases
 Place the stethoscope over lung tissue, not over
bony prominences.
 At each placement of the stethoscope, listen to at
least one cycle of inspiration and expiration.
 Note the pitch (e.g., high, low), duration of sound,
and presence of adventitious or abnormal sounds.

Auscultation Cont …d
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 At each placement of the stethoscope, listen to at
least one cycle of inspiration and expiration.
 Note the pitch (e.g., high, low), duration of sound,
and presence of adventitious or abnormal sounds.
 The lung sounds are heard anteriorly from a line
drawn
perpendicular to the xiphoid process lateral to the
midclavicular line.
 Palpate inferiorly (down) two ribs in the midaxillary
line and around to the posterior chest. .

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 This gives you a fairly accurate and easy
way to determine the lung fields to be
auscultated
 When documenting the location of the lung
sounds, divide the anterior and posterior
lung into thirds (upper, middle, and lower)
and note, for example, “crackles posterior
right lower lung field.”
 You are not expected to define which lobe
of the lung has particular lung sounds

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 The three normal breath sounds are vesicular,
bronchovesicular, and bronchial.
 Vesicular sounds are relatively soft, lowpitched, gentle,
rustling sounds.
 They are heard over all lung areas except the major
bronchi. Vesicular sounds have a 3:1 ratio, with
inspiration three times longer than expiration.
 Bronchovesicular sounds have a medium pitch and
intensity and are heard anteriorly over the mainstem
bronchi on either side of the sternum and posteriorly
between the scapulae.
 Bronchovesicular sounds have a 1:1 ratio, with
inspiration equal to expiration.

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 Bronchial sounds are louder and higher pitched and
resemble air blowing through a hollow pipe.
 Bronchial sounds have a 2:3 ratio with a gap between
inspiration and expiration.
 This reflects the short pause between the respiratory
cycles.
 To hear the likeness of bronchial breath sounds, place
the stethoscope alongside the trachea in the neck.
 The term abnormal breath sounds describes bronchial or
bronchovesicular sounds heard in the peripheral lung
fields.

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 Adventitious sounds are extra breath
sounds that are abnormal. Adventitious
breath sounds include crackles, rhonchi,
wheezes, and pleural friction rub
(described in Table 26-7).
 A variety of terms are used to describe
breath sounds. The spoken voice can be
auscultated over the thorax just as it can
be palpated for fremitus.
 Egophony is positive (abnormal) when the
person says “E” but it is heard as “A.”

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Palpation
Description Possible Etiology and
Significance
Tracheal deviation
Leftward or rightward
movement of trachea
from normal midline
position.
Nonspecific indicator of change in
position of mediastinal structures.
Medical emergency if caused by
tension
pneumothorax. Trachea deviates
to the side opposite the collapsed
lung.
Altered tactile
fremitus
Increase or decrease in
vibrations.
↑ In pneumonia, pulmonary
edema. ↓ In pleural effusion, lung
hyperinflation. Absent in
pneumothorax, atelectasis.
Altered chest
movement
Unequal or equal but
diminished movement of
two sides of chest with
inspiration.
Unequal movement caused by
atelectasis, pneumothorax,
pleural effusion, splinting. Equal
but diminished movement caused
by barrel chest, restrictive
disease, neuromuscular disease.

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Palpation
Description Possible Etiology
and Significance
Percussion
Hyperresonance
Loud, lower-pitched
sound over areas that
normally produce
a resonant sound.
Lung hyperinflation
(COPD), lung collapse
(pneumothorax),
air trapping (asthma).
Dullness
Medium-pitched
sound over areas that
normally produce a
resonant sound.
↑ Density (pneumonia,
large atelectasis), ↑
fluid in pleural
space (pleural
effusion).

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Auscultation
and Significance
Fine crackles
Series of short-duration, discontinuous,
high-pitched sounds heard just before the
end of inspiration. Result of rapid
equalization of gas pressure when
collapsed alveoli or terminal bronchioles
suddenly snap open. Similar sound to
that made by rolling hair between fingers
just behind ear.
Idiopathic pulmonary fibrosis,
interstitial edema (early
pulmonary edema), alveolar
filling (pneumonia), loss of lung
volume (atelectasis), early
phase of heart failure.
Coarse crackles
Series of long-duration, discontinuous,
low-pitched sounds caused by air
passing through airway intermittently
occluded by mucus, unstable bronchial
wall, or fold of mucosa. Evident on
inspiration and, at times, expiration.
Similar sound to blowing through straw
under water. Increase in bubbling quality
with more fluid.
Heart failure, pulmonary
edema, pneumonia with
severe congestion, COPD.
Rhonchi
Continuous rumbling, snoring, or rattling
sounds from obstruction of large airways
with secretions. Most prominent on
expiration. Change often evident after
coughing or suctioning.
COPD, cystic fibrosis,
pneumonia, bronchiectasis.

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Auscultation
and Significance
Wheezes
Continuous high-pitched
squeaking or musical sound
caused by rapid vibration of
bronchial walls. First evident
on expiration but possibly
evident on inspiration as
obstruction
of airway increases. Possibly
audible without stethoscope.
Bronchospasm (caused by
asthma), airway obstruction
(caused by foreign body,
tumor), COPD.
Stridor
Continuous musical or crowing
sound of constant pitch. Result
of partial obstruction of larynx
or trachea.
Croup, epiglottitis, vocal cord
edema after extubation,
foreign body.
Absent breath sounds
No sound evident over entire
lung or area of lung.
Pleural effusion, mainstem
bronchi obstruction, large
atelectasis, pneumonectomy,
lobectomy.

Sequence for examination of chest
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 Sequence for examination of the chest. A, Anterior sequence. B, Lateral sequence. C,
Posterior sequence. For palpation, place the palms of the hands in the position
designated as “1” on the right and left sides of the chest. Compare the intensity of
vibrations. Continue for all positions in each sequence. For percussion, tap the chest at
each designated position, moving downward from side to side. Compare percussion
sounds at all positions. For auscultation, place the stethoscope at each position and
listen to at least one complete inspiratory and expiratory cycle. Keep in mind that, with a
female patient, the breast tissue will modify the completeness of
the anterior examination.

Auscultation Cont..d
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 Bronchophony is positive (abnormal) when a person
repeats “ninety-nine” and the words are easily
understood and are clear and loud.
 Whispered pectoriloquy is positive (abnormal) when
the patient whispers “one-two-three” and the almost
inaudible voice is transmitted clearly and distinctly.
 Conditions that increase lung density or a
consolidated lung (e.g., pneumonia) have positive
(abnormal) voice sounds.

4/10/2024 By Abdi Wakjira( Bsc, Msc) 39
UPPER RESPIRATORY
DISORDERS

Types of Rhinitis
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1. Allergic Rhinitis - is the reaction of the
nasal mucosa to a specific allergen.
Allergic rhinitis can be classified according to
the causative allergen (seasonal or perennial)
or,
 the frequency of symptoms (episodic,
intermittent, or persistent).
 Episodic refers to symptoms related to
sporadic exposure to allergens that are not
typically encountered in the patient’s normal
environment, such as exposure to animal

Allergic Rhinitis …
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Intermittent means that the symptoms are
present less than 4 days a week or less than 4
weeks per year.
Persistent means that the symptoms are
present more than 4 days a week and for
more than 4 weeks per year

Pathophysiology
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 Sensitization to an allergen occurs with initial allergen exposure,
which results in the production of antigen-specific immunoglobulin
E (IgE).
 After exposure, mast cells and basophils release histamine,
cytokines, prostaglandins, and leukotrienes.
 These cause the early symptoms of sneezing, itching,
rhinorrhea, and congestion.
 Four to 8 hours after exposure, inflammatory cells infiltrate
the nasal tissues, causing and maintaining the inflammatory
response.
 Because symptoms of rhinitis resemble those of the common
cold, the patient may believe the condition is a continuous or
repeated cold.

Clinical Manifestations
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 Manifestations of allergic rhinitis are initially
sneezing; watery, itchy eyes and nose; altered
sense of smell; and thin, watery nasal discharge that
can lead to a more sustained mucus production and
nasal congestion.
 The nasal turbinates appear pale,boggy, and
swollen.
 C/M is characterized by 4 cardinal symptoms of
watery Rhinorrhoea, nasal obstruction, nasal itching
and sneezing.

Clinical Manifestations Cont…d
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 The posterior ends of the turbinates can become so
enlarged that they obstruct sinus aeration or
drainage and result in sinusitis.
 With chronic exposure to allergens, the patient’s
responses include headache, congestion, pressure,
nasal polyps, and postnasal drip as the most
common cause of cough.
 The patient may complain of cough, hoarseness,
and the recurrent need to clear the throat.
Congestion may cause snoring

DIAGNOSIS OF Allergic Rhinitis
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The diagnosis of AR is based on a typical history of
allergic symptoms and diagnostic tests.
When 2 or more symptoms out of watery Rhinorrhoea,
sneezing, nasal obstruction and nasal pruritus persist for
≥1 hour on most days, Allergic Rhinitis is strongly
suspected
Skin testing
Skin testing is the most important to find offending
allergens.
There are various testing methods including the scratch,
prick/
puncture, intradermal and patch tests.
 The radioallergosorbent test (RAST);Serum specific
IgE level

TREATMENT OF ALLERGIC RHINITIS
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 Requires a stepwise approach depending on the
severity and duration of symptoms.
 Treatment options for AR consist of
a) Allergen avoidance,
b) Pharmacotherapy,
c) Immunotherapy and
d) Surgery.
The four major categories of medications used to
manage cold symptoms are antihistamines,
decongestants, antitussives, and expectorants.

Pharmacotherapy
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An over-the-counter (OTC), non-sedating
antihistamine
Competitively inhibit the interaction of histamine
with H1 receptors.
They prevent and relieve nasal itching,
sneezing, and Rhinorrhoea, and ocular
symptoms,
e.g.
Loratadine 10 mg once daily
Desloratadine 5 mg once daily
Cetirizine 10 mg once daily or divided BID
Levocetirizine 5 mg once daily in the

Intranasal corticosteroids
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Are potent inhibitors of the late-phase allergic
reaction in Allergic Rhinitis.
They inhibit recruitment of Langerhans cells,
macrophages, mast cells, T cells, and
eosinophils into the nasal mucosa
They control itching, sneezing, Rhinorrhoea, and
stuffiness
E.g.
Beclomethasone dipropionate 2 sprays
EN/day
Fluticasone (Flonase), 1–2 sprays EN /day

Decongestants
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Decrease swelling of the nasal mucosa which, in
turn, alleviates nasal congestion
e.g. Oxymetazoline nasal spray
60 mg every 4-6 h
120mg ER every 12h
240mg ER once daily
Pseudoephedr
ine pills

NURSING AND COLLABORATIVE
MANAGEMENT
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 The most important step in managing allergic rhinitis
is identifying and avoiding triggers of allergic
reactions
 The goal of medications is to reduce inflammation
associated with allergic rhinitis, reduce nasal
symptoms, minimize associated complications, and
maximize quality of life.
 Appropriate oral medication options include:
H1-antihistamines, corticosteroids, decongestants, and
leukotriene receptor antagonists (LTRAs).

NURSING AND COLLABORATIVE
MANAGEMENT Cont …d
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 Second-generation antihistamines are
preferred over first generation antihistamines
because of their nonsedating effects.
 Remind patients who are taking
antihistamines to have adequate fluid intake to
reduce adverse symptoms.
 Nasal corticosteroid sprays are used to
decrease inflammation locally with little
absorption in the systemic circulation.
 Therefore systemic side effects are rare.

2. Non-Allergic Rhinitis
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This form of rhinitis does not depend on the
presence of IgE and is not due to an allergic
reaction.
The symptoms can be triggered by cigarette
smoke and other pollutants as well as strong
odors, alcoholic beverages, and cold.
Other causes may include blockages in the nose,
a deviated septum, infections, and over-use of
medications such as decongestants.

3. Acute viral Rhinitis
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 Acute viral rhinitis (common cold or acute
coryza) is an infection of the upper respiratory
tract that can be caused by more than 200
different viruses.
 The majority of colds, which are caused by
rhinoviruses, are mild and self-limiting.
 Cold symptoms may last 2 to 14 days, with
typical recovery in 7 to 10 days.
 Caution patients to use the intranasal
decongestant sprays for no more than 3 days
to prevent rebound congestion from occurring.
 Cough suppressants may be used.

3. Acute viral Rhinitis Cont…d
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 Complications of acute viral rhinitis include pharyngitis,
sinusitis, otitis media, tonsillitis, and lung infections.
 Unless symptoms of complications are present,
antibiotic therapy is not indicated.
 If symptoms remain for 10 to 14 days with no
improvement, acute bacterial sinusitis may be present,
and antibiotics will be prescribed.
 Teach the patient to recognize the symptoms of
secondary bacterial infection, such as a temperature
higher than 100.4° F (38° C); tender, swollen glands;
severe sinus or ear pain; or significantly worsening
symptoms.

Nasal polyp
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 Def: is a non cancerous growth(benign) develop on
the lining of the passage at sinuses.
 Small growth may cause no problem,
 Big growth may cause complications.
 It may come in many sizes & shapes.
Causes - exact cause is unknown
Risk factors – person with chronic viral or bacterial
infections have a higher incidence of nasal polyps.
Allergies, asthma, chronic rhinitis, and chronic sinusitis

Cont …d
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Incidence
Common in adult
Rare in children
 4 times are common in men than in women.

Clinical Manifestation
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 Bluish, glossy projections in the nares –
can exceed the size of grape
 Nasal congestion, nasal discharges
(usually clear mucus), speech distortion
 Reduced ability to smell (hyposmia)
 Loss of smell (anosmia)

Types
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 Antrochoanal polyps – single, unilateral and usually
found in children, originate from maxillary sinus
 Ethmoidal polyps – multiple, bilateral and usually found
in adults, originating form ethmoidal air cells

Medical management
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 Corticosteroid sprays or local injection of a
steroid into the polyp
 Steroid used to reduce the size, prevention
of recurrence and reduction of
inflammation thus reducing swelling
 Antibiotics (amoxicillin or erythromycin) if
infection present.

Surgical Management
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 Polypectomy – removal of polyps after nose is
anesthetized, NASAL SNARE is slipped around polyp,
which is transected and removed with forceps.
 Removal of polyp via CALDWELL- LUC OPERATION,
 Procedure named after George Caldwell & Guy
Luc,who desgined an operation to remove infected
polypoid tissue

Epistaxis
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Def:
Epistaxis (nosebleed) occurs in a bimodal distribution,
with children 2 to 10 years of age and adults over age
50 most affected.
Epistaxis can be caused by:
 low humidity, allergies,
 upper respiratory tract infections,
 sinusitis, trauma, foreign bodies,
 hypertension,
 chemical irritants such as street drugs, overuse of
decongestant nasal sprays, facial or nasal surgery,

Epistaxis Cont…d
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Epistaxis can be caused by ….
 Anatomic malformation, and tumors.
 Any condition that prolongs bleeding time or
alters platelet counts will predispose the
patient to epistaxis.
 Bleeding time may also be prolonged if the
patient takes aspirin, NSAIDs, warfarin, or
other anticoagulant drugs.

Nursing and collaborative management
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 Use simple first aid measures to control
epistaxis:
 (1) keep the patient quiet;
 (2) place the patient in a sitting position,
leaning slightly forward with head tilted
forward; and
 (3) apply direct pressure by pinching the
entire soft lower portion of the nose against
the nasal septum for 10 to 15 minutes.
 If bleeding does not stop within 15 to 20
minutes, seek medical assistance.

Nursing and collaborative …
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 Medical management involves identifying the bleeding
site and applying a vasoconstrictive agent,
 Cauterization, or anterior packing.
 Pledgets (nasal tampon) impregnated with anesthetic
solution (lidocaine) and/or
 Vasoconstrictive agents such as cocaine or epinephrine
are placed into the nasal cavity and left in place for 10 to
15 minutes.
 Silver nitrate may be used to chemically cauterize an
identified bleeding point after epistaxis is controlled.
 Thermal cauterization is reserved for more severe
bleeding and requires the use of local or general
anesthesia.

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 If bleeding does not stop, packing may be used. Packing with
compressed sponges (e.g., Merocel) or epistaxis balloons
(e.g., Rapid Rhino) is preferred over the use of traditional
Vaseline ribbon gauze
 The balloon is inflated with air to achieve the same pressure
effect.
 Closely monitor respiratory rate, heart rate and
rhythm,
 Oxygen saturation using pulse oximetry (SpO2), and
 Level of consciousness, and observe for signs of aspiration.
 Because of the risk of complications, all patients with
posterior packing should be admitted to a monitored unit to
permit closer observation.

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 Nasal packing may be left in place for a few days.
 Before removal, medicate the patient for pain because
this procedure is very uncomfortable.
 After removal, cleanse the nares gently and lubricate
them with water-soluble jelly.
 Instruct the patient to avoid vigorous nose blowing,
engaging in strenuous activity, lifting, and straining for 4
to 6 weeks.
 Teach the patient to use saline nasal spray and/or a
humidifier, to sneeze with the mouth open, and to avoid
the use of aspirin-containing products or NSAIDs.

Sinusitis
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Four pairs of paranasal
sinuses
1. Frontal-above eyes in
forehead bone
2. Maxillary-in cheekbones,
under eyes
3. Ethmoid-between eyes and
nose
4. Sphenoid-in center of skull,
behind nose and eyes

Sinusitis---
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An acute inflammatory process
involving one or more of the
paranasal sinuses.
A complication of 5%-10% of
URIs in children.
Persistence of URI symptoms
>10 days without improvement.
Maxillary and ethmoid sinuses
are most frequently involved.

Types of Sinusitis
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It is typically classified by:_
Duration of illness (acute vs. Chronic)
Etiology (infectious vs. Noninfectious)
 Pathogen type (viral, bacterial, or fungal)
1. Acute Sinusitis – respiratory symptoms last longer than
10 days but less than 30 days.
2. Sub acute sinusitis – respiratory symptoms persist longer
than 30 days without improvement.
3. Chronic sinusitis – respiratory symptoms last longer than
120 days.

Pathophysiology of sinusitis
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If the sinus orifices are blocked by swollen mucosal lining,
the pus cannot enter the nose and builds up pressure
inside the sinus cavities
Postnasal drainage causes obstruction of nasal passages
and an inflamed throat.
With inflammation, the mucosal lining of the sinuses
produce mucoid drainage. Bacteria invade and pus
accumulates inside the sinus cavities.
Inflammation and edema of mucous
membranes lining the sinuses cause
obstruction.
Rhinitis or abrupt pressure changes (air planes,
diving) or dental extractions or infections.

Predisposing Factors
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Allergies,
Cold weather
High pollen counts
Day care attendance
Smoking in the home
Reinfection from siblings
Anatomical: septal deviation, nasal
deformities, nasal polyps
Mucociliary functions: cystic fibrosis, immotile
cilia syndrome.
Systemic disease: immune deficiency.: DM,
AIDS,

Etiology
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Acute sinusitis
Str. pneumoniae %41
H. influenzae %35
M. catarrhalis %8
Others %16
 Strep. pyogenes
 S. aureus
 Rhinovirus
 Parainfluenzae
 Veilonella,
peptococcus
Chronic sinusitis
Anaerob bacteria:
 Bactroides,
fusobacterium
 S. Aureus
 Strep. Pyogenes
 Str. Pneumoniae
 Gram (-) bacteria
fungi

Signs and Symptoms
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Headache, congestion, facial pain, fatigue, and
cough,
Purulent nasal discharge.
Pain over the region of the affected sinuses
If a maxillary sinus is affected, the patient
experiences pain over the cheek and upper
teeth.
In ethmoid sinusitis, pain occurs between and
behind the eyes.
Pain in the forehead typically indicates
frontal sinusitis.
Fever may be present in acute infection, with or

Diagnosis of sinusitis
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History ;persistent symptom of URI and physical findings
Radiographic studies
Opacification and mucosal thickening air filled level
Others :
Translumination of sinus cavity
Sinus aspirate culture
Nasal endoscopy
If repeated episodes occur:-
 x-ray examination
 computed tomography (CT) scan
 magnetic resonance imaging (MRI)

Treatment of Sinusitis
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Nondrug measures :
Maintain adequate hydration(drink 6-10glasses of
liquid )
Personal Steam vaporizer
Apply warm facial packs (warm wash cloth, hot
water bottle)
Saline irrigation lavage or sniff (1/4 teaspoon salt
dissolved in 1cup of water )
Sleep ahead of bed elevated
Adequate rest
Avoid cigarette smoke and extremely dry or cool air

Drug Treatment
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Antibiotics
First-line:
 Amoxicillin, 1.5 to 3.5 g/d divided 2 or 3 times daily)
 Trimethoprim–sulfamethoxazole 800/160 mg twice
daily
Second-line:
 Amoxicillin–Clavulanate (500/125 mg 3 times daily)
Second- or third-generation cephalosporin
 Cefuroxime, 250 or 500 mg twice daily,
Doxycycline 200 mg on first day then 100 mg twice
daily for 2 to 10 days

Antibiotics----
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Macrolides :
Clarithromycin, 500 mg twice daily or
Azithromycin, 500 mg daily for 5 days
Fluoroquinolones :
Ciprofloxacin, 500 twice a day or
Levofloxacin, 500 mg once daily
Oral antihistamines :Loratadine, 10 mg daily
Nasal decongestant: Xylometazoline intranasally, 2 to 3
sprays every 8 to 10 hr.
Nasal steriods :Fluticasone, 2 puffs) intranasally [200 µg]
daily
Acetaminophen or ibuprofen is given for pain and fever.

Nursing management
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Patient teaching self care
 Instruct patient to blow the nose gently and to use tissue to
remove the nasal drainage.
 Increasing fluid intake,
 Applying local heat (hot wet packs), and
 Elevating the head of the bed promote drainage of the sinuses.
 Instructs the patient about the importance of medication
regimen.

Tonsillitis
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Tonsils are protective (lymph) glands that are
situated on both sides in the throat.
The tonsils constitute an important part of the
body's immune system and are vital defense
organs.
They protect the body from bacteria and viruses
by fighting these as soon as they enter the body
(via the oral / nasal cavity).
Inflammatory process of the mucosa and
structures of the pharyngo-tonsillar area, usually
of infectious origin
Tonsillitis is contagious.

Tonsillitis ---
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Clinical Manifestations
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Throat pain, either mild or severe.
Swallowing with difficulty.
Odynophagia, pharyngeal exudate, anterior cervicolateral
lymphadenopathy, scarlet rash and headache
Chills and fever as high as 104° F (40° C) or more.
Swollen lymph glands on either side of the jaw.
Ear pain.
Cough (sometimes).
Vomiting (sometimes).
Refusal to eat in a very young child.
Erythema,
Edema,
Ulcer or vesicles

Causes of Tonsillitis
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Viruses: Rhinovirus, adenovirus, influenza virus,
Para influenza virus,Coxsackie virus and Epstein-
Barr virus
Aerobic Bacteria: GABHS and other streptococcal
species, Neisseria gonorrhoeae, Corynebacterium
diphtheriae.
Yeast :Candida species.
Spirochetes:Treponema pallidum (syphilis)

Causes ----
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Assessment and Diagnostic
Findings
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History :look at throat to see red
and swollen tonsils with spots or
sores.
Throat culture: rapid strep test
Blood test ;done to confirm
presence of infection

Medical Management
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 Bed rest, except to use the bathroom, is necessary
until fever subsides.
DIET
 Supportive measures include Increase all fluid intake.
While the throat is very sore, use liquid nourishment,
such as milk shakes, soups, and high-protein fluids
(diet or instant-breakfast milk drinks).
Viral tonsillitis is not effectively treated with antibiotic
therapy.
Tonsillectomy if complicated

Antibiotic treatment of choice
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 Penicillin V: <12 years or <27 kg: 250mg / 12h 10 days
>12 years or >27 kg: 500mg / 12h 10 days
 Penicillin G Benzathine:
<12 years or <27 kg: 600.000 UI, single dose
>12 years or >27 kg: 1.200.000 UI, single dose
 Amoxicillin: 50mg /kg/day, every 12-24 hours, 10 days,
with a maximum dose of 500mg /12h or 1g/24h.
 Mediated by IgE:
- Azithromycin: 20mg/kg /day, once a day, 3 days
(maximum 500mg/day)
- Clindamycin: 20-30mg/kg /day, every 8-12h, 10 days
(maximum 900mg/day).

Indications for tonsillectomy
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Recurrent tonsillitis (more than seven per year
Persistent, chronic tonsillitis
Recurrent peritonsillar abscess with previous
history of recurrent or persistent tonsillitis.
Unilateral tonsillar hypertrophy.
Hemorrhagic tonsillitis.
Chronic tonsillolithiasis.
Nasal obstruction with speech abnormalities,
orodental abnormalities.

Complications of tonsillitis
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 Classified into suppurative and nonsuppurative
complications.
 The nonsuppurative complications include
 Scarlet fever,
 Acute rheumatic fever, and
 Post-streptococcal glomerulonephritis.
Suppurative complications include
Peritonsillar, parapharyngeal and retropharyngeal
abscess formation.

Pharyngitis
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ACUTE PHARYNGITIS:is a sudden painful
inflammation of the pharynx, the back portion of the throat
that includes the posterior third of the tongue, soft palate,
and tonsils.
It is commonly referred to as a sore throat
Causes
 Viral infection- most common(adenovirus, influenza
virus, Epstein-Barr virus, and herpes simplex virus)
 Bacterial infection-Group A beta-hemolytic
streptococcal bacterial infection called strep throat.

Cont….d
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Pathophysiology
Viral/ strep throat infection
The body responds by triggering an inflammatory response
in the pharynx.
This results in pain, fever, vasodilation, edema, and tissue
damage, manifested by redness and swelling in the tonsillar
pillars, uvula, and soft palate.
A creamy exudate may be present in the tonsillar pillars
If caused by GA hemolytic streptococcus- it may be severe
If caused by uncomplicated virus- may be subside
promptly(3 to 10 days after the onset).

Cont….d
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Complications
Sinusitis
Otitis media
Peritonsillar abscess
Mastoiditis
Cervical adenitis
In rare cases, the infection may lead to bacteremia,
pneumonia, meningitis, rheumatic fever, and
nephritis.

Cont….d
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Clinical features
Fiery-red pharyngeal membrane and tonsils
Lymphoid follicles that are swollen and flecked with
white-purple exudate, and enlarged
Tender cervical lymph nodes
No cough
Fever
Malaise
Sore throat

Cont….d
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Cont….d
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 Assessment and dxs
Accurate diagnosis of pharyngitis is essential to determine
the cause (viral or bacterial)
Newer and more rapid diagnostic tests (eg, the rapid
streptococcal antigen test (RSAT).
Medical mgt
For virus- supportive care
For bacterial-penicillin is a drug of choice if allergic and
resistance (clarithromycin and azithromycin) may be used.
Analgesic medications, as prescribed( i.e. Aspirin or
acetaminophen)can be taken

Cont….d
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Nursing management
Instructs the patient to:_
 Stay in bed during the febrile stage of illness and
 Full course of antibiotic therapy
Preventive measures
 Not sharing eating utensils, glasses, napkins, food, or towels;
cleaning telephones after use
 Using a tissue to cough or sneeze
 Disposing of used tissues appropriately
 Avoiding exposure to tobacco and secondhand smoke.

Cont….d
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Chronic pharyngitis:- is a persistent inflammation of the
pharynx.
Types
 Hypertrophic: characterized by general thickening and
congestion of the pharyngeal mucous membrane
 Atrophic: probably a late stage of the first type (the
membrane is thin, whitish, glistening, and at times
wrinkled)
 Chronic granular (“clergyman’s sore throat”),
characterized by numerous swollen lymph follicles on the
pharyngeal wall

Cont….d
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Common in person :_
 work in dusty surroundings
 Use their voice to excess
 Suffer from chronic cough
 Habitually use alcohol and tobacco.
Clinical manifestation
 Sense of irritation or fullness in the throat,
 Mucus that collects in the throat and can be expelled by
coughing
 Difficulty swallowing.

Cont….d
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Medical management
Nasal congestion medications (ephedrine sulfate
(Kondon’s Nasal) or phenylephrine hydrochloride)
Antihistamine decongestant medications, such as
Pseudoephedrine.
For adults with chronic pharyngitis, tonsillectomy is an
effective option.
Nursing management
Avoid alcohol, tobacco, secondhand smoke, and exposure to
cold or to environmental or occupational pollutants.

LARYNGITIS
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DEFINITION
It is the inflammation
of larynx leading to
oedema of laryngeal
mucosa and
underlying
structures.

ETIOLOGY
102
INFECTIOUS:
 Viral laryngitis can be caused by rhinovirus, influenza
virus, parainfluenza virus, adenovirus, coronavirus,
and RSV.
 Bacterial laryngitis can be caused by group A
streptococcus, streptococcus pneumoniae, C.
diphtheriae, M. catarrhalis,haemophilus
influenzae, bordetella pertussis, and M. tuberculosis.
 Fungal laryngitis can be caused by Histoplasma,
Candida (especially in immunocompromised persons)

NON INFECTIOUS
 Inhaled fumes
 Acid reflux disease
 Allergies
 Excessive coughing, smoking, or alcohol
consumption.
 Inflammation due to overuse of the vocal cords
 Prolonged use of inhaled corticosteroids for asthma
treatment
 Thermal or chemical burns
 Laryngeal trauma, including iatrogenic one caused by
endotracheal intubation

Predisposing factors
 Smoking
 Psychological strain
 Physical stress
 Voice abuse misuse
 Acid reflux (GERD)
 Frequent sinus infectionsr
 Types – acute (less then 3 weeks)and
chronic (more than 3 weeks )

Pathophysiology
 Due to etiological factors
 The mucosa of the larynx becomes
congested and may become oedematous.
 A fibrinous exudate may occur on the
surface.
 Signs and symptoms
 Sometimes infection involves the
perichondrium of laryngeal cartilages
producing perichondritis.

Types of Laryngitis
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 1. Acute Laryngitis
 2. Chronic laryngitis
1. Acute laryngitis:
Def: It is the inflammation of larynx which
lasts less than a few days & leads to edema
of laryngeal mucosa & underlying structures.
Most cases of AL are temporary & improve
after the underlying causes get better.

Acute Laryn ….
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 Frequently caused by ‘Rhinovirus”
 Other causative Organisms:
 Para influenza virus
 Respiratory syncytial virus
 Adeno virus
 Measles & Mumps
 Bacterial infection- such as Diphteria,
these are rae.

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 Vocal misuse, vocal strain or yelling or
over use of the voice.
 Exposure to noxious
 Viral infections such as that cause a cold.
 Frank aphonia

Chronic Laryngitis
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 Laryngitis that lasts more than 3 weeks is
known as chronic laryngitis.
 More persistent disorder that produces
lingering hoarseness & other voice
changes
 It is usually painless & has no significant
sign of infection.

Etiology
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 Vocal misuse
 Exposure to noxious agent.
 Infectious agents leading to upper
respiratory tract infections. Most often viral
but some times bacterial
 Inhaled irritants such as chemical fumes,
allergens or smoking.
 Acid reflex, also gastro esophageal reflux
disease (GERD)

Cont …d
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 Chronic sinusitis, bronchitis
 Excessive alcohol use
 Habitual over use of the voice such as with singers
or cheerleaders.
 Smoking
Less common cause of chronic laryngitis include:
 Infections such as TB, syphilis or a fungal infections.
 Infections with certain parasites.
 Cancer
 Vocal cord paralysis, which can result from injury,
stroke or a lung tumor or other conditions.

Clinical features
 Husky, high pitched voice, Body aches, Fever, Malaise.
 Dysphonia (hoarseness) or aphonia (inability to speak)
 Dysphagia (difficulty in swallowing)
 Dyspnea (difficulty in breathing), predominantly in
children
 Dry, burning throat, Dry irritating paroxysmal cough.
 Cold or flu-like symptoms , Swollen lymph nodes in the
throat, chest, or face
 Hemoptysis (coughing out blood), Increased production
of saliva.

Clinical features Cont…d
 Signs of acute URTI.
 Dry thick sticky secretions.
 Dusky red and swollen vocal cords.
 congestion of laryngeal mucosa.

Treatment
SUPPORTIVE
 Voice rest.
 Steam inhalation.
 Cough suppressants.
 Avoid smoking and cold climate.
 Fluid intake.

Diagnosis
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 Based upon a combination of a complete
history & physical exam.
 If symptoms are severe, particularly in
children, the doctor may order an x-ray of
the neck & chest.
 CBC Some times in children rarely in
adults.

Laryngoscopy
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 Visual examination of vocal cords in a procedure
called laryngoscopy, by using a light & a tiny
mirror to look in to the back of the throat.
 Fiber optic -laryngoscopy
 Biopsy

Treatment
DEFINITIVE
 If laryngitis due to gastroesophageal reflux, an H2-
inhibitor (ranitidine) or proton-pump inhibitor
(omeprazole) is used to reduce gastric
acid secretions.
 If laryngitis is caused by thermal or chemical burns,
steroids are used.
 In viral laryngitis, drinking sufficient fluids will be
helpful.
 If laryngitis is due to a bacterial or fungal infection,
appropriate antibiotic or antifungal therapy is
given.

Supportive Therapy
 Drinking lot of fluids - Drink 7-9 glasses of water per day;
herbal tea and chicken soup also provides soothing effect.
 maintaining good general health - Exercise regularly.
 Avoiding smoking - They are bad for the heart, lungs and
vocal tract.
 Eating a balanced diet - Include vegetables, fruits and
whole grain foods.
 Avoid dry, artificial interior climates.
 Do not eat late at night - may have problems when
stomach acid backs up on the vocal cords.
 Use a humidifier to assist with hydration.

Laryngotracheal bronchitis (Viral croup)
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 Known as laryngotracheitis or
laryngotracheobronchitis
 Most common etiology is viral
Parainfluenza virus, adenovirus, RSV
 Leads to infection and inflammation of the
larynx and subglottic area
 Decreased mobility of the vocal cords
 Frequently affects children

Etiology
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 Most common etiology is viral Parainfluenza
virus, adenovirus, RSV
 Leads to infection and inflammation of the larynx
and subglottic area
 Decreased mobility of the vocal cords
 Frequently affects children

Clinical manifestation
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 Begins with respiratory symptoms
 Within 2 days progresses to:
 Hoarseness
 Barking seal like cough
 Stridor-
 Symptoms worse at night
 Fever

Viral Croup
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 Mild disease: occasional barking cough, no
strider at rest, mild to no suprasternal
retractions
 Moderate: frequent cough, audible strider at
rest, retractions,
 Severe: frequent cough, Barking type
 inspiratory/expiratory strider, retractions,
decreased air entry, distress, and agitation.

Viral Croup Cont …d
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 A/P neck x-ray: Shows subglottic
narrowing
 CBC might show lymphocytosis-
DDx:
 Diphtheria
 Epiglottitis
 Peritonsillar abscess
 Inhalation injuries

Viral Croup Management
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 Moist steam
 Exposure to out door cool air
 Adequate hydration
 Glucocorticoid
 Racemic epinephrine
 Dexamethasone for severe cases

Hospitalization Indication
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 Dehydration-
 Significant respiratory compromise
 Signs of respiratory failure
Spasmodic Croup
 No prodrome of upper respiratory
syndrome.
 Subglottic edema
 Affects individual at night.
 Affects children between 1-3 years
 Managed at home

Epiglottitis
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Def:
 The epiglottis is a cartilaginous structure covered
with mucous membrane.
 Epiglottitis is an acute inflammation of the epiglottis
and pharyngeal structures
 Can be severe life threatening disease
 Primarily affects children 2-7 years.
 Presents more acutely in young children
Etiology: H. influenzae type B, also group A S
pneumoniee, H pereintluensee, S sureus, and beta
hemolytic streptococci

C/M
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 Triad of drooling, dysphagia, and distress.
 High fever
 Positioning- tripod position
 Dyspnea/inspiratory stridor/ accessory
muscle use/muffled voice
 Brassy cough

Diagnosis
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 Lateral neck –enlarged, edematous epiglottis.
 Laryngoscopy: Direct inspection of epiglottis
under controlled conditions
 Leukocytosis
 Blood cultures positive

Differential Dx
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 Anaphylaxis
 Croup
 Retropharyngeal Abscess
 Foreign body obstruction

Epiglottitis Management
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 Secure airway with endotracheaI
intubation.
 Might need cricothyroidotomy.
 Child should sit upright
 Humidified oxygen
 Hospitalization
 No tongue blades
 IV antibiotics: Ceftriaxone (Rocephin)
cefotaxime (Ceftin), Ampicillin with
chloramphenicol

Epiglottitis Management ….
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 Evaluate for extubation 24-48 hours post
intubation.
 Rifampin prophylaxis for 4days for
household contacts if: children in
household have not been vaccinated with
the entire series

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Management of pt with respiratory disorder
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Oxygen Therapy
 Is the administration of oxygen at a concentration greater than
that found in the environmental atmosphere
 The goal of oxygen therapy is to provide adequate transport of
oxygen in the blood while decreasing the work of breathing
and reducing stress on the myocardium
Indications
 Change in the patient’s respiratory rate or pattern( hypoxemia
or hypoxia)
 Need for oxygen is assessed by arterial blood gas analysis,
pulse oximetry, and clinical evaluation.

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 Oxygen therapy is the administration of oxygen at a
concentration greater than that found in the
environmental atmosphere.
 At sea level, the concentration of oxygen in room air is
21%.
 The goal of oxygen therapy is to provide adequate
transport of oxygen in the blood while decreasing the
work of breathing and reducing stress on the
myocardium.
 Oxygen transport to the tissues depends on factors such
as cardiac output, arterial oxygen content, concentration
of hemoglobin, and metabolic requirements.
 These factors must be kept in mind when oxygen

Indications
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 A change in the patient’s respiratory rate or pattern
may be one of the earliest indicators of the need for
oxygen therapy.
 The change in respiratory rate or pattern may result
from hypoxemia or hypoxia.
 Hypoxemia - a decrease in the arterial oxygen
tension in the blood is manifested by changes in
mental status.
Such as:
 progressing through impaired judgment,
 agitation,
 disorientation,

Indications Cont …d
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 Sign & symptoms of hypoxemia include:
 confusion,
 lethargy, and coma,
 dyspnea,
 increase in blood pressure,
 changes in heart rate,
 dysrhythmias,
 central cyanosis (late sign),
 diaphoresis, and cool extremities.
 Hypoxemia usually leads to hypoxia, which is a
decrease in oxygen supply to the tissues.
Hypoxia, if severe enough, can be life-
threatening.

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 The signs and symptoms signaling the need for
oxygen may depend on how suddenly this need
develops.
 With rapidly developing hypoxia, changes occur in
the central nervous system because the higher
neurologic centers are very sensitive to oxygen
deprivation.
 The clinical picture may resemble that of alcohol
intoxication, with the patient exhibiting lack of
coordination and impaired judgment.

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 Longstanding hypoxia (as seen in chronic obstructive
pulmonary disease [COPD] and chronic heart failure)
may produce fatigue, drowsiness, apathy,
inattentiveness, and delayed reaction time.
 The need for oxygen is assessed by arterial blood gas
analysis and pulse oximetry as well as by clinical
evaluation.
Cautions in Oxygen Therapy
As with other medications, the nurse administers oxygen
with
caution and carefully assesses its effects on each patient.
Oxygen is a medication and except in emergency
situations is administered only when prescribed by a

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 In general, patients with respiratory conditions are
given oxygen therapy only to raise the arterial
oxygen pressure (PaO2) back to the patient’s normal
baseline, which may vary from 60 to 95 mm Hg.
 In terms of the oxyhemoglobin dissociation curve the
blood at these levels is 80% to 98% saturated with
oxygen; higher inspired oxygen flow (FiO2) values
add no further significant amounts of oxygen to the
red blood cells or plasma.

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Types of Hypoxia:
Hypoxia can occur from either severe
pulmonary disease (inadequate oxygen
supply) or from extrapulmonary disease
(inadequate oxygen delivery) affecting gas
exchange at the cellular level.
The four general types of hypoxia are
hypoxemic hypoxia, circulatory hypoxia,
anemic hypoxia, and histotoxic hypoxia.

Types of Hypoxia Cont …d
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1. Hypoxemic Hypoxia
 Hypoxemic hypoxia is a decreased oxygen level in
the blood resulting in decreased oxygen diffusion
into the tissues.
 It may be caused by hypoventilation, high altitudes,
ventilation–perfusion mismatch (as in pulmonary
embolism), shunts in which the alveoli are collapsed
and cannot provide oxygen to the blood (commonly
caused by atelectasis), and pulmonary diffusion
defects.
 It is corrected by increasing alveolar ventilation or
providing supplemental oxygen

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2. Circulatory Hypoxia
 Circulatory hypoxia is hypoxia resulting from inadequate
capillary circulation.
 It may be caused by decreased cardiac output, local
vascular obstruction, low-flow states such as shock, or
cardiac arrest.
 Although tissue partial pressure of oxygen (PO2) is
reduced, arterial oxygen (PaO2) remains normal.
 Circulatory hypoxia is corrected by identifying and
treating the underlying cause.

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3. Anemic Hypoxia
Anemic hypoxia is a result of decreased effective
hemoglobin concentration, which causes a
decrease in the oxygen-carrying capacity of the
blood. It is rarely accompanied by hypoxemia.
Carbon monoxide poisoning, because it reduces
the oxygen-carrying capacity of hemoglobin,
produces similar effects but is not strictly anemic
hypoxia because hemoglobin levels may be
normal

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4. Histotoxic Hypoxia
Histotoxic hypoxia occurs when a toxic substance,
such as cyanide, interferes with the ability of
tissues to use available oxygen

OXYGEN TOXICITY
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 Oxygen toxicity may occur when too high a
concentration of oxygen (greater than 50%) is
administered for an extended period (longer than 48
hours).
 It is caused by overproduction of oxygen free
radicals, which are byproducts of cell metabolism.
 If oxygen toxicity is untreated, these radicals can
severely damage or kill cells.
Antioxidants such as vitamin E, vitamin C, and beta-
carotene may help defend against oxygen free
radicals. (Scanlan, Wilkins & Stoller, 1999).

OXYGEN TOXICITY Cont…d
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Signs and symptoms of oxygen toxicity
include:
 substernal discomfort,
 paresthesias,
 dyspnea,
 restlessness,
 fatigue,
 malaise,
 progressive respiratory difficulty, and
 alveolar infiltrates evident on chest x-rays.

SUPPRESSION OF VENTILATION
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 In patients with COPD, the stimulus for respiration is a
decrease in blood oxygen rather than an elevation in
carbon dioxide levels.
 Thus, administration of a high concentration of oxygen
removes the respiratory drive.
 The resulting decrease in alveolar ventilation can cause
a progressive increase in arterial carbon dioxide
pressure (PaCO2), ultimately leading to the patient’s
death from carbon dioxide narcosis and acidosis.
 Oxygen-induced hypoventilation is prevented by
administering oxygen at low flow rates (1 to 2 L/min).

OTHER COMPLICATIONS
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 Because oxygen supports combustion, there
is always a danger of fire when it is used. It is
important to post “no smoking” signs when
oxygen is in use.
 Oxygen therapy equipment is also a potential
source of bacterial cross-infection; thus, the
nurse changes the tubing according to
infection control policy and the type of oxygen
delivery equipment.

Methods of Oxygen Administration
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 Oxygen is dispensed from a cylinder or a
piped-in system.
 A reduction gauge is necessary to reduce the
pressure to a working level, and a flow meter
regulates the flow of oxygen in liters per
minute.
 When oxygen is used at high flow rates, it
should be moistened by passing it through a
humidification system to prevent it from
drying the mucous membranes of the
respiratory tract.

Methods of Oxygen Administration …
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 Oxygen delivery systems are classified as low-flow or
high-flow delivery systems.
1. Low-flow systems contribute partially to the inspired
gas the patient breathes.
The amount of inspired oxygen changes as the patient’s
breathing changes.
Examples of low-flow systems include:
1. nasal cannula,
2. oropharyngeal catheter,
3. simple mask,
4. partial-rebreather and
5. non-rebreather masks.

Methods of Oxygen Administration …
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2. High-flow systems provide the total amount of inspired
air.
 A specific percentage of oxygen is delivered independent
of the patient’s breathing.
 High-flow systems are indicated for patients who require
a constant and precise amount of oxygen.
Examples of such systems include:
1. transtracheal catheters,
2. Venturi masks,
3. aerosol masks,
4. tracheostomy collars,
5. T-piece, and
6. face tents

Chest physiotherapy
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 Includes postural drainage, chest percussion,
and vibration, and breathing retraining.
• The goals of CPT are to remove bronchial
secretions, improve ventilation, and increase
the efficiency of the respiratory muscles.

Postural drainage
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Allows the force of gravity to assist in the removal of
bronchial secretions.
The secretions drain from the affected bronchioles into
the bronchi and trachea and are removed by coughing
or suctioning.
Used to prevent or relieve bronchial obstruction caused
by accumulation of secretions.
Patient usually sits in an upright position, secretions are
likely to accumulate in the lower parts of the lungs.

Positions used for postural drainage
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Nursing Management
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• The nurse should be aware of:-
Patient’s diagnosis as well as the lung lobes or segments
involved
Cardiac status
Any structural deformities of the chest wall and spine
• Auscultating the chest before and after the procedure is
used to identify the areas that need drainage and assess
the effectiveness of treatment
• The nurse explores strategies that will enable the patient
to assume the indicated positions at home(use of objects
readily available at home, such as pillows, cushions, or
cardboard boxes

Cont…d
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• PD is usually performed two to four times
daily, before meals (to prevent nausea,
vomiting, and aspiration) and at bedtime
• The nurse makes the patient as comfortable as
possible in each position and provides an
emesis basin, sputum cup, and paper
tissues.
• If the patient cannot cough, the nurse may
need to suction the secretions mechanically.

Chest Percussion and Vibration
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Thick secretions that are difficult to cough up may be
loosened.
Help dislodge mucus adhering to the bronchioles and
bronchi.
Percussion is carried out by cupping the hands and lightly
striking the chest wall in a rhythmic fashion over the lung
segment to be drained.
The patient uses diaphragmatic breathing during this
procedure to promote relaxation
percussion over chest drainage tubes, the sternum, spine,
liver, kidneys, spleen, or breasts (in women) is avoided.
Percussion is performed cautiously in the elderly (b/c of
increase incidence of osteoporosis and risk of rib fracture)

Vibration
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• Is the technique of applying manual
compression and tremor to the chest wall during
the exhalation phase of respiration
Helps increase the velocity of the air expired
from the small airways, thus freeing the mucus.
After three or four vibrations, the patient is
encouraged to cough, contracting the abdominal
muscles to increase the effectiveness of the
cough

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Fig. showing Percussion and vibration. A. Proper hand position
for vibration. B. Proper technique for vibration. The wrists and
elbows remain stiff; the vibrating motion is produced by the
shoulder muscles. C. Proper hand position for percussion.

Nursing Management
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The nurse ensures that the patient is
comfortable, is not wearing restrictive
clothing, and has not just eaten.
Gives medication for pain, as prescribed,
before percussion and vibration and splints any
incision and
 Provides pillows for support as needed.

Cont …d
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Deep Breathing and Coughing
Effective coughing can keep the airways clear of
secretions.
An ineffective cough is exhausting and fails to bring up
secretions.
Instruct the patient to take two or three deep breaths,
using the diaphragm.
This helps get the air behind the secretions.
After the third deep inhalation, tell the patient to hold
the breath and cough forcefully.
This is repeated as necessary.
Good hydration can facilitate this process.

Incentive Spirometry
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Def:
 Incentive spirometry, also referred to as sustained
maximal inspiration (SMI).
 Incentive Spirometry is designed to mimic natural
sighing or vomiting by encouraging the patient to
take long, slow, deep breaths.
 This is accomplished by using a device that provides
patients with visual or other positive feed back when
they inhale at a predetermined flow rate or volume
& sustain the inflation for at least 5 seconds.

Purpose
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 To increase tran-pulmonary pressure &
inspiratory volumes, improve inspiratory
muscle performance, & re- establish or
simulate the normal pattern of pulmonary
hyperinflation.
 When the procedure is repeated on a
regular basis, airway patency may be
maintained & lung atelectasis prevented &
reversed.

Cont …d
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Indication:
Upper abdominal or thoracic- surgery
Lower abdominal surgery
 Prolonged bed rest
 Surgery in patients with COPD
 Lack of pain control
 Presence of thoracic or abdominal binders.

Using an Incentive Spirometer
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 The inhalation of air, in a slow and controlled manner,
helps inflate the lungs.
 The marker within the spirometer will measure the depth
of each breath.
 Assume an upright position if possible (sitting or semi-
Fowler’s).
 Breathe using your diaphragm.
 Place mouthpiece firmly in the mouth, to breathe in
deeply and slowly, holding each breath in for 3–4
seconds and exhaling slowly.
 Repeat 6–10 times per session.
 Use spirometer every hour while awake (keep it within
reach).
 Try coughing, with splinting of incision, after each use.

Incentive spirometer
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 How to use an incentive spirometer

ARTIFICIAL AIRWAYS
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 The patient with an airway disorder such as a
laryngeal obstruction or cancer may require the use
of a temporary or, in some cases, a permanent
artificial airway.
 Two types of artificial airways that may be used
include an endotracheal tube (ETT) or a
tracheostomy tube.
 General recommendations are to favor a
tracheostomy tube rather than ETT if the patient will
be intubated for 21 days or greater, and to favor the
ETT over a tracheostomy if support will be required
for 10 days or less (Morris et al., 2013).

ARTIFICIAL AIRWAYS Cont…d
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ETT and tracheostomy tubes have several
disadvantages.
 The tubes cause discomfort,
 the cough reflex is depressed because
closure of the glottis is hindered, and
 Secretions tend to become thicker because
the warming and humidifying effect of the
upper respiratory tract has been bypassed.

ARTIFICIAL AIRWAYS Cont…d
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 The swallowing reflexes are depressed
because of prolonged disuse and the
mechanical trauma produced by the
endotracheal or tracheostomy tube, thus
increasing the risk of aspiration.
 In addition, ulceration and stricture of the
larynx or trachea may develop.
 Of great concern to the patient is the inability
to talk and to communicate needs.

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Endotracheal intubation
• involves passing an endotracheal tube through
the mouth or nose into the trachea.

Cont …d
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It is a means of providing an airway for patients
who cannot maintain an adequate airway on their
own
Comatose patients,
Patients with upper airway obstruction),
For patients needing mechanical ventilation,
For suctioning secretions from the pulmonary
tree

Cont …d
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• Tracheotomy
• is a surgical procedure in which an opening is made into the
trachea.
• The indwelling tube inserted into the trachea is called a
tracheostomy tube
• It may be either temporary or permanent.
Equipment
 Sterile gloves
 Hydrogen peroxide
 Normal saline solution or sterile water
 Cotton-tipped applicators
 Dressing
 Twill tape
 Type of tube prescribed, if the tube is to be changed

Cont …d
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• A tracheotomy is used
To bypass an upper airway obstruction,
To allow removal of tracheobronchial secretions,
To permit the long-term use of mechanical
ventilation,
To prevent aspiration of oral or gastric secretions
in the unconscious or paralyzed patient (by closing
off the trachea from the esophagus)
To replace an endotracheal tube

Tracheostomy tube in place
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Tracheostomy tubes. A. Cuffed tracheostomy tube; used for
patients on mechanical ventilation. B. Cuffed fenestrated tube;
allows the patient to talk. C. Uncuffed tracheostomy tube; not
used for adult patients on mechanical ventilation; often used for
permanent tracheostomy patients who are not ventilator
dependent.
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Nursing Management
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Continuous monitoring and assessment.
Newly made opening must be kept patent by
proper suctioning of secretions.
The patient is placed in a semi-fowler’s position
to facilitate ventilation, promote drainage,
minimize edema, and prevent strain on the
suture lines After the vital signs are stable
Analgesia and sedative agents must be
administered with caution because of the risk of
suppressing the cough reflex.

Preventing Complications Associated With
Endotracheal and Tracheostomy Tubes
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• Administer adequate warmed humidity.
• Maintain cuff pressure at appropriate level.
• Suction as needed per assessment findings.
• Maintain skin integrity.
• Change tape and dressing as needed or per
protocol.
• Auscultate lung sounds.
• Monitor for signs and symptoms of infection,
including temperature and white blood cell count.

Cont …d
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• Administer prescribed oxygen and monitor
oxygen saturation.
• Monitor for cyanosis.
• Maintain adequate hydration of the patient.
• Use sterile technique when suctioning and
performing tracheostomy care.

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Lower Respiratory Tract Disorders

Pneumonia
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 Pneumonia (from the Greek pneuma, “breath”) is a
potentially fatal infection and inflammation of the lower
respiratory tract (i.e., bronchioles and alveoli) usually caused
by inhaled bacteria and viruses
 Is an inflammation of the lung parenchyma.
 Is a lung infection involving the lung alveoli (air sacs) and
can be caused by microbes, including bacteria, viruses, or
fungi.
 Pneumonitis -- immune-mediated inflammation of alveoli
Clinical Definition
Symptoms of acute LRT infection
a) Cough, sputum, chest pain
b) Fever,sweating,shiver, aches and pains
• New focal chest signs on examination OR

Classification of pneumonia
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Based on causative agent
Bacterial or typical pneumonia,
Atypical pneumonia
Viral pneumonia
Fungal pneumonia etc

Pneumonia
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 Anatomic(morphological) classification
Lobar pneumonia- homogeneous consolidation of one
or more lung lobes
Broncho- pneumonia- multiple patchy shadows in a
localized or segmental area.

Bronchopneumonia
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Infants + young children and the elderly.
Usually secondary to other conditions associated with
local and general defense mechanisms:
Viral infections (influenza, measles)
Aspiration of food or vomitus
Obstruction of a bronchus (foreign body or
neoplasm)
 Inhalation of irritant gases
Major surgery
Chronic debilitating diseases, malnutrition

Lobar pneumonia:
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 S. pneumoniae.
 Previously healthy individuals.
 Abrupt onset.
 Unilateral stabbing chest pain on inspiration
(due to fibrinous pleurisy).

Types of Pneumonia
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Community-acquired pneumonia(CAP)
 Infection of the pulmonary parenchyma acquired
from exposure in the community
Occurs either in the community setting or within
the first 48 hours after hospitalization or
institutionalization.
Infection usually spread by droplet inhalation.
Highest incidence in winter
Smoking important risk factor

“Typical” CAP:
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 History
Previously healthy with sudden onset of fever and
shortness of breath
Presents with “typical” severe, acute infection
Infectious agent (usually S. Pneumonia or H. Flu) is
culturable/ identifiable
Responsive to cell-wall active antibiotics
 Physical signs and symptoms
Tachycardia
Tachypnea
Productive cough with purulent sputum and possible
hemoptysis

Typical CAP----
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• localized:
− dullness to percussion
− decreased breath sounds
− crackles ,ronchi , egophony
Investigations
• CXR showing lobar consolidation
• CBC showing leukocytosis w/ left shift
• Sputum sample contains neutrophil, RBCs; Gram
stain may be positive depending on organism

“Atypical” CAP
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• History :
Previously healthy present with is usually sub-acute,
low grade fever, sore throat, and intractable cough
Minimal sputum production
Able to continue to work
No sick contacts, recent travel, or evidence of altered
immune system
PE reveals a mildly ill-appearing patient with diffuse
wheezes on lung exam
“Walking pneumonia” syndrome
Causative pathogens are difficult to culture/identify by
standard methods
Not responsive to penicillins

Types Of Atypical Pneumonia.
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 Mycoplasma pneumonia
 Caused by tiny bacteria mycoplasma pneumoniae.
 It is generally milder than other types
 Children and adults who are infected often show symptoms resembling
those of a cold or flu, such as coughing, sneezing, and a mild fever.
 Generally, not have to be hospitalized.
 Chlamydophila pneumonia.
 Caused by chlamydophila pneumoniae bacteria.
 School-age children at greatest risk for this type.
 Legionella pneumonia (legionnaires’ disease)
 Caused by legionella pneumophila bacteria.
 Not spread through person-to-person contact.
 Legionnaires’ disease tends to be more serious than other types of
atypical pneumonia.
 It can lead to respiratory failure and death in some cases.

Common causes Of CAP
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 The causative agents for CAP that requires hospitalization are:
 Previously healthy individual: → S. pneumoniae
 Pre-existing viral infection → Staph. aureus or S. pneumoniae
 Chronic bronchitis → Haemophilus influenzae or S. pneumoniae
 AIDS → Pneumocystis carinii, cytomegalovirus, TB
 Elderly people and those with co morbid illnesses → H. Influenzae
 Legionella, pseudomonas Aeruginosa, and other gram-negative rods.
 Viruses (infants and children)
 Atypical bacteria

The most common causes for viral
pneumonia are:
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 Influenza
 Parainfluenza
 Adenovirus
 Respiratory syncytial virus (RSV)
 appears mostly in children
 Cytomegalovirus
 In immunocompromised hosts

Features of Severe Pneumonia
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 ‘Core’ clinical adverse prognostic features
(CURB)
Confusion
Urea > 7 mM (>19.1 mg/dL)
Respiration rate >30 /min
Blood Pressure: Systolic BP < 90 mm Hg and/or
diastolic BP ≤ 60 mmHg
NOTE: Patients with 2 or more CURB are at high
risk of death

Hospital-Acquired Pneumonia
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 Also known as nosocomial pneumonia
 Is defined as the onset of pneumonia symptoms more than 48
hours after admission in patients with no evidence of infection
at the time of admission.
 Is an acute lower respiratory tract infection acquired after at
least 48 hours of admission to hospital and is not incubating at
the time of admission.
 Ventilator-associated pneumonia (VAP), is pneumonia occurring
more than 48 hours after endotracheal intubation.

Predisposing factors
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 Defense mechanisms are incompetent or overwhelmed
 Decreased cough and epiglottal reflexes (may allow
aspiration)
 Mucociliary mechanism impaired
 Pollution
 Cigarette smoking
 Upper respiratory infections
 Tracheal intubation
 Aging
 Metabolic disorder
 Mechanical ventilation (VAP)
 Supine positioning and aspiration


Pneumonia
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The common organisms responsible for HAP
Enterobacter species,
Escherichia coli,
H. influenzae,
Klebsiella species,
Proteus, Serratia marcescens,
P. aeruginosa,
methicillin-sensitive or methicillin-resistant
Staphylococcus aureus (MRSA), and
S. pneumoniae

Pneumonia
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Pneumonia in the Immunocompromised Host
Includes Pneumocystis pneumonia (PCP), fungal
pneumonias, and Mycobacterium tuberculosis.
Aspiration Pneumonia
Is the pulmonary consequences resulting from entry of
endogenous or exogenous substances into the lower
airway.

Pathophysiology of Pneumonia
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 Pneumonia results from the proliferation of microbial
pathogens at the alveolar level and the host's response
to those pathogens
 Their are three mechanisms by which pathogens reach
to the lungs
Inhalation,
Aspiration and
Hematogenous e.g. Tricuspid endocarditis

Pathophysiology pneumonia----
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Primary inhalation: when organisms bypass
normal respiratory defense mechanisms or when
the Pt inhales aerobic GN organisms that colonize
the upper respiratory tract or respiratory support
equipment
Aspiration: occurs when the Pt aspirates
colonized upper respiratory tract secretions
Stomach: reservoir of GN that can ascend,
colonizing the respiratory tract.
Hematogenous: originate from a distant source
and reach the lungs via the blood stream.

Pathology of lobar pneumonia
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 Four stage of pathiophysiological change occur due to
pneumonia
1. Congestion
Lasts < 24 hours: Out pouring of fluid from
tissue to alveoli- b/se of inflammatory process.
Alveoli filled with oedema fluid and bacteria.
Only a few neutrophil are seen at this stage.

Stage of pathiophysiological----
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2. Red hepatization
 Lungs look like the liver
 Firm, 'meaty' and airless appearance of lung.
 Alveolar capillary dilatation.
 Strands of fibrin extending from one alveolus to another
via inter-alveolar pores of Kohn.
 Also neutrophil in alveoli.
 Pleura: Fibrinous exudate.
 Characterized microscopically by the presence of many
RBC, neutrophil, micro-organisms , fibrins in the alveolar
spaces

Stage of pathiophysiological---- …
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3. Gray hepatization
 Less hyperaemia.
 Macrophages, neutrophil + fibrin
 The lung is dry, friable and gray-brown to yellow as
a consequence of a persistent fibrino-purulent
exudates
 WBC and fibrin consolidate the alveoli and lung
 Second and third stages last for 2 to 3 days each

Stage Of Pathiophysiological----
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4. Resolution
 Lyses and removal of fibrin via sputum + lymphatics.
 Begins after 8-9 days (without antibiotics).
 Sudden improvement of patient's condition.
 Characterized by enzymatic digestion of the alveolar
exudate;
 Resorption, phagocytosis or coughing up of the residual
debris and
 Restoration of the pulmonary architecture.

Clinical manifestations
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Cough producing greenish or yellow sputum
High fever that may be accompanied by
shaking chills
Shortness of breath
Tachypnea
Pleuritic chest pain
 Headache

Clinical manifestations…
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Sweaty and clammy (moist) skin,
Loss of appetite
Fatigue
Blueness of the skin
Nausea, vomiting
Mood swings
Joint pains or muscle aches

Investigations
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History
Physical exam
Chest x-ray
Gram stain of sputum
Sputum culture and sensitivity
Pulse oximeter or ABGs
CBC, differential, chemistry
Blood cultures
Invasive diagnostic techniques
 Transtracheal aspiration
 Bronchoscopy with a protected brush catheter
 Direct needle aspiration of the lung

What are the differential diagnoses?
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Alternative
diagnosis
Supporting clinical feature(s)
Exacerbation of
COPD
Known COPD, history of smoking, or industrial exposure to
inorganic dust,Bilateral polyphonic wheeze
Lack of focal chest signs
Exacerbation of
asthma
History of asthma or atopy, Bilateral polyphonic wheeze
Lack of fever and focal chest signs
Pulmonary oedema Features of left ventricular or biventricular failure (elevated
jugular venous pressure, peripheral oedema, fine bibasal
crackles in the lung)
Bronchiectasis longer history,Finger clubbing
Chronic cough productive of purulent sputum
Bilateral crackles at the lung bases
Lung cancer Haemoptysis, weight and appetite loss, smoking history
Finger clubbing
Lymphadenopathy
Cachexia

Medical management
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EMPIRIC ANTIBIOTIC THERAPY
First line (Mild):Amoxicillin 1g PO TID #5-7days and if penicillin allergy
Clarithromycin 250gm PO BID #5-7days
(Moderate): Benztylpencillin 1.2g IM QID #7days
plus
Doxycycline100mg PO BID #7days
or
Clarithromycin 500gm PO BID #7days
If penicillin allergy Cefriaxone 1gm Iv daily #7days plus
Doxycycline100mg PO BID #7days or Clarithromycin 500gm PO BID
#7days
(Severe): Benztylpencillin 1.2g IM every 4hours
plus
Gentamycin IV daily plus
Azithromycin 500mg IV/PO daily
If penicillin allergy :Cefriaxone 1gm Iv daily #7days plus Azithromycin
500mg IV/PO daily

Pneumonia cont’d…
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Medical management…
E.g. according to DACA
For community acquired ambulatory pts
(mild pneumonia):-
◦ Amoxicillin
OR
◦ Erythromycin
OR
◦ Doxycyciline

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For community acquired hospitalized pts (severe
pneumonia):-
Non-Drug treatment:
Bed rest
Frequent monitoring of temperature, blood pressure and
pulse rate.
Give attention to fluid and nutritional replacements
Administer Oxygen
Analgesia for chest pain

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Drug treatment:
Benzyl penicillin PLUS Gentamicin
OR Ceftriaxon.
Pneumonia due to staphylococcus aureus:
Cloxacillin 1-2 gm, IV or IM QID for 10-14 days.

Pneumonia
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HAP (nosocomial pneumonias)
Antimicrobials effective against gram-negative & gram-positive
should be given in combination. Suitable combination is:
Cloxacillin plus Gentamicin
OR
Ceftriaxone plus Gentamicin
Ciprofloxacin
Pneumocytis pneumonia responds to Trimethoprin +
Sulfamethoxazole

Complications of Pneumonia
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 Abscess formation
 Empyema
 Failure of resolution ⇒ intra-alveolar scarring
('carnification') ⇒ permanent loss of Ventilatory function of
affected parts of lung.
 Bacteraemia:
 Infective endocarditis
 Cerebral abscess / meningitis
 Septic arthritis
 Shock and Respiratory Failure
 Pleural Effusion
 Atelectasis

Sample case scenarios
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1. A 35-year-old male patient presented to Nekemte Specialized hospital with fever
and cough. He was well 3 days back, when he suffered the onset of nasal
stuffiness, mild sore throat, and a cough productive of small amounts of clear
sputum. On Physical examination his temperature was 38.9°C , pulse 110
beats/min and regular, and his respiratory rate is 18 breaths/min. The case most
likely?
2. A 65-year-old man presented to the emergency department a few hours after the
gradual onset of left-sided weakness and expressive aphasia. On admission all
Vital signs were normal. However, On the fourth hospital day, Unfortunately, his
temperature increases to 39.3C with concomitant coughing that sounds
productive. Basilar rales are audible at the right lung base. A chest radiograph
reveals the presence of a new right lower lobe infiltrate without an associated
pleural effusion. The case most likely?

Chronic Obstructive Pulmonary Disease
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 COPD is also known as:
 Chronic obstructive lung disease (COLD),
 Chronic obstructive airway disease (COAD),
 Chronic airflow limitation (CAL) and
 Chronic obstructive respiratory disease (CORD)
 It is pulmonary disease characterized by airflow limitation
that is not fully reversible.
 Refers to chronic bronchitis and emphysema, a pair of two
commonly co-existing diseases of the lungs in which the
airways become narrowed.
 This leads to a limitation of the flow of air to and from the
lungs causing shortness of breath

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 In COPD, less air flows in and out of the airways because of one
or more of the following:
The airways and air sacs lose their elastic quality.
The walls between many of the air sacs are
destroyed.
The walls of the airways become thick and inflamed.
The airways make more mucus than usual, which tends
to clog them.

Causes
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 Smoking
 Occupational exposures
 Air pollution
 sudden airway constriction in response to
inhaled irritants,
 Bronchial hyperresponsiveness, is a
characteristic of asthma.
 Genetics-Alpha 1-antitrypsin deficiency

Pathophysiology of COPD
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Abnormal inflammatory response of the lungs
due to toxic gases
Response occurs in the airways, parenchyma &
pulmonary vasculature.
Narrowing of the airway takes place
Destruction of parenchyma leads to
emphysema.
Destruction of lung parenchyma leads to an
imbalance of proteinases / antiproteinases.
Pulmonary vascularchanges
Mucus hyper secretion dysfunction(cilia
dysfunction,airflowlimitation,corpulmonale(RVF)
Chronic cough and sputum production

Clinical features
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Chronic cough
Sputum production
Wheezing
Chest tightness
Dyspnea on exertion
Wt.loss
Respiratory insufficiency
Respiratory infections
Barrel chest- chronic hyperinflation leads to loss of
lung elasticity

DIFFERENTIAL DIAGNOSIS
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Diagnosis Suggestive feature
COPD •Onset mid-life
•Symptom slowly progressive
•History of tobacco smoking
Asthma •Onset early in life
•Symptom varies widely from day to day
•Symptom worse at night/morning
•Family history
Congestive heart failure •Chest X-ray shows dilated heart, pulmonary
edema
•Pulmonary function test shows volume restriction
not airway limitation
Bronchiectasis •Large volume of purulent sputum
•Commonly associated with bacterial infection
•Chest x-ray shows bronchial dilation
Tuberculosis •Onset all ages
•Chest x-ray shows infiltrate
•Microbiological confirmation

Assessment
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 DX: Spirometry is required to make the diagnosis; the
presence of a post-bronchodilator FEV1/FVC < 0.70
confirms the presence of persistent airflow limitation.
 According to Modified British Medical Research
Council (mMRC) :
 mMRC Grade 0:Only get breathlessness with extraneous
exercise
 mMRC Grade 1: I get short of breath when hurrying the
level
 mMRC Grade 2:I walk slower than people of the same
age the level b/se of breathlessness
 mMRC Grade 3: I stop for breath after walking 100m
 mMRC Grade 4:I am too breathlessness to leave the
house

COPD includes
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I. Bronchitis
II. Emphysema

Bronchitis
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 Bronchitis is a condition in which the bronchial tubes
become inflamed.
 Acute (short term) and chronic (ongoing).
 Infections or lung irritants cause acute bronchitis.
 Chronic bronchitis is an ongoing, serious condition.
 It occurs if the lining of the bronchial tubes is
constantly irritated and inflamed, causing a long-term
cough with mucus.

Chronic bronchitis
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Presence of recurrent or chronic productive cough for a
minimum of 3 months for 2 consecutive years.
It is defined as the presence of cough and sputum
production for at least 3 months.
Risk factors
 Bronchial irritants (e.g. cigarette smoke, exposure to
pollution)
 Genetic predisposition (alpha-1 antitrypsin deficiency)
 Respiratory infections

Chronic Bronchitis: Pathophysiology
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Chronic inflammation
Hypertrophy & hyperplasia of bronchial glands that secrete
mucus
Increase number of goblet cells
Cilia are destroyed
Bronchial smooth muscle hyper reactivity

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Narrowing of airway
 airflow resistance
 work of breathing
Hypoventilation & CO2 retention  hypoxemia &
hypercapnea

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Bronchial walls thickened, bronchial lumen narrowed,
and mucus may plug in the airway
Alveoli become damaged and fibrosed,
Altered function of the alveolar macrophages.
The patient becomes more susceptible to respiratory
infection.

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230
Mucus plug
Normal lumen

Signs and symptom
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Acute
 sore throat,
 fatigue (tiredness),
 fever, body aches,
 stuffy or runny nose,
 vomiting, and
 Diarrhea
 persistent cough
 cough may produce
clear mucus
 shortness of breath
Chronic
coughing,
wheezing, and
chest discomfort.
The coughing may
produce large amounts of
mucus. This type of cough
often is called a smoker's
cough.

Diagnosis
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 History - medical history
 Whether you've recently had a cold or the flu
 Whether you smoke or spend time around others
who smoke
 Whether you've been exposed to dust, fumes,
vapors, or air pollution –
 Mucus -to see whether you have a bacterial infection
 chest x ray
 lung function tests,
 CBC
 ABG analysis

Nursing management of patient with Respiratory DO.pptx

Nursing management of patient with Respiratory DO.pptx

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