Respiratory System _Pneumonia&tuberculosis_Ms_75B_Test1, Chapter 28

Front 1

Respiratory structure:

Back 1

_URT=Upper respiratory tract=NPET=nose, pharynx, epiglostis,tracheo
_LRT=Lower respiratory tract=bronchi,alveoli
_Lung
*Anatomy: R.:3 lobes, straighter, shorter=>aspiration:food falling in, need to listen to lung sound in R.base when assess); L:2lobes
***Any condition of MENTAL staus/SWALLOWING ability may effect/impair funx of epiglostis and INCR RISK for aspiration/pneumoia(EX:DECR LOC, head injury, Tracheostomy tube, resuscitation efford(over breathing). CVA.
*Visceral pleura
*Compliance (distensibility, diffusion)
_Surfactant=DECR surface tension in alveoli=>If DECR pressure needed to inflate alveoli, help DECR tendency of alveoli to collapse.
_Chest wall:is shaped & support by Ribs & Sternum
_Visceral pleura & Lung:Lung are lined with membrance visceral Pleura.
_Intrapleural space & problem
_Diaphragm:major muscle of the respiratory sys.
+Inspiration:diaphragm contracts, thoracix cavity INCR, thoracix Pressure DECR=>AIR IN
+ Expiration=passive, telastic recoil of chest wall and lung allow chest to passively return to normal position=>AIR OUT
***PHRENIC NERVE innervate(stimulate to action) diaphragm.

Front 2

Blood supply_2 types of circulation:
_Pulmonary circulation
_Bronchial circulation

Back 2

_Pulmonary circulation: -O2 blood from R. ventrical thru Pulmonary artery is supplied for LUNG=>gas exchange at LUNG=>O2 blood fr.LUNG thru Pulmonary Vein is supply the Heart at L.Atrium.
_Bronchial circulation:Bronchial arteries , arrives form thoracic aorta, provide O2 to bronchi and other Lung tissues.

Front 3

Intrapleural space:
_Def:
_Problem:

Back 3

Intrapleural space:
_Def:
+Contain 20-25 cc fluid=lubricant=>help layers of pleural slide on each other during breathing.
+INCR cohesion between the layers that facilitate expansion during inspiration
_Problem:
+Too much fluid in the sac=Pleural Effusion=clear liquid
+Purulent fluid wict bacteria infection=Empyema

+

Front 4

Diaphragm:
_Inspiration
_Expiration
**Phrenic nerve ____ diaphragm

Back 4

Major muscle of Resp.
_Inspiration: D contract,INCR cavity of the thoracix(lung anf chest wall)=>DECR the Pressure in the thoracix cavity =>AIR MOVE IN
_Expiration:passive, elastic recoil of chest wall and lung to noramal position.Thoracix pressure INCR=>AIR MOVE OUT

Front 5

Compliance( Distensibility of Lung)

Back 5

_Ability to stretch, measure of elasticity of the lung anf the Thorax.
_When compliance DECR, lung harder to inflate
EX: Pleuro Effusion, Pulmonary Fibrosis/sarcoidosis, Pul. edema.
_With Aging
* AP(anterioposterial) of the chest diameter INCR=>Barrel chest.
*Aveoli 's wall destruction
*DECR elastic recoil.

Front 6

Diffusion process thru the Lung

Back 6

O2 IN, CO2 Out over/cross capillary membrane.

Front 7

Respiratory DEFENSE sys.

Back 7

_Mucus:100ml/day_by mucociliary clearance sys.
_Cilia:Cover airway fr. trachea to bronchioles.Beat rhythmiclly to move mucus for the lung.What istrap in the area either cought OUT or Swallow.
_Cough reflex: Protective mechanism/reflex.Clear airway by high PRESSURE and VELOCITY. Remove effectively secretion Above large & main airway.
_Alveolar macrophages: eat , swallow bacteria. Debris move up by the cilia and cough out or Lymph sx carry out.

Front 8

Aging and Respiratory Sys.

Back 8

_DECR elastic recoil
_DECR chest wall compliance(distensibility)
_ INCR AP(anterioposterial) diameter =>barell chest.
_DECR number of Fnx alveoli
_DECR resp defense mechanis=>less effective
_Less forceful cough
_Less Fnx cilias.

Front 9

P.561: Diagnostic Study& its purposes

Back 9

Radiology:
_Chest X-Ray= screen, dx, evaluate changes
_CT scan=for Dx of lesions difficut to assess by conventional X-Ray study.Posteranterial/lateral
_MRI=Dx of lesions difficult to asscess by CT scan(lung apex near spine..)
_Pulmonary Angiogram=study to:*visulize Pulmonary vasculature*locate obstruction/pathologic condition_contrast medium,injected thru catheter into Pul arteries/right side of H.
_PET:distinguish benign & maglinant lung nodules, IV injection of radioisotope.
Endoscopic examination:
_Bronchoscopy:Dx, biopsy, specimen collection, take pic of changes, suction mucus, remove forgein objects...
Others:
_Thoracentesis:aspirate fluid
_Pulmonary Fnx test:Lung Volume and Air Flow

Front 10

Acute BRONCHITIS

Back 10

1/Def:
_Inflamation of LRT due to infection.frequent w/ COPD, but not always bcuz it can occur as sequela( abnormality following other disease) to URT=>acute bronchitis.
_Self limitting
_If acute bronchitis > 3mths( becuz exacerbation)=> pt get chronic bronchitis
2/ Causes: viral, strep, rhnovirus, influenza( bact could sit on top of chronic or standing on becuz you have URI)
3/S/S:cough, clear/purulent sputum, general malaise, T/P/R INCR, breath may be normal, X-Ray not consolidation or infiltrate.
4/ Tx: Fluid, Rest, cough suppresant, antibiotic(COPD), bronchodilator.

Front 11

ATELECTASIS(can lead to pneumonia)

Back 11

1/Def:
_Collapse of lung tissue at any structural level result with interference ith natural FORCES that promote lung expansion
_Common in POST-OP, especially with pt has CHEST, ADB surgery or fracture ribs, found in elderly at Bed rest.
_Detected by X-RAy 1st( bcuz: some pt mabe Asymptomatic)
_If postoperation, PT have INCR Temp.=>he has Atelectasis.
2/ S&S: dysapnea, tachypnea, tachycardia, cyanosis, DECR breath sound, Crackles, Fever(101 F)
3/ Prevention(Surgical Nurse)
_Frequent posioning
_Early ambulation
_ Deep Breathing
_Effective coughing
_Insetive spirometry
_Oxygen
_Postural drainage
_Suctioning
****Early S&S of INadequate Oxygen:
+CNS:unexplained apprehensive or unexplained restlessness(irritability)
+Resp:tachypnea ; dyspnea on exertion.
+Cardio:tachycardia, mild HTN
==> check VS, O2 SAT.

Front 12

PNEUMONIA:
1/ Def:
2/Etiology Risk factors:
*Protective mechanism;
3/Pathophysiology
4/Classification;
5/Clinical manifestation
6/Difinitive Diagnostic test
7/ Other types of Pneu.in Immunocompromised patient
8/Complication
9/Tx
10/Prevention(HMO)

Back 12

1/ Def:inflammatory process in the lung structure a/s with increasing in interstitial & alveolar fluid, Decrese Gas Exchange
2/Etiology Risk factors:
_Virulence or quantity of infective agent
_Viral or bacteria
_Microplasm & fungi
*Protective mechanism: impaired by air polution, smoking, URI, aging, decrease filtration, decrease warming(cold), decrease humidication
3/Patho:
With Pneumonia, inflamatory and pulmonary response to offending agent (body react to offending agent). It is happened in 3 ways:
+Aspiration of organism what in nasopharynx, oralpharynx into lung.
+Inhalation:of microbe in the air (mycoplasma pneumonia, fungi pneumonia, smoke, dust, gases, chemical)
+Hematogenous:spread fr. primary infection (staph.)=>staph. pneumonia)

4/Classification:
_Community accquire:pt come to the hospital with it=> incubation. S/S in 2 days
_Hospital accquire:after 48h of admission.Pneumonia has highest motality and mobility of NOsocomial Infection. N.need to becareful with the Asepsic technique.
5/Clinical manifestation:
_Fever, chill, sweat.
_Cough, N/V
_Dyspnea, pleuritic chest pain
_Sputum production (green, bloody, rusty)
_Headache, sorethroat
_Crackling sound fr. fluid in interstitial area (tactile Femitus), INCR vibrating.
_Chest sound like bronchial breath sound over area of consolidation(tubular_loud sound)
_Unequal chest wall expansion(if large enough area)
_In elderly: can see mental confusion

6/Difinitive Diagnostic test:
_Blood test(WBC)
_Skin test
_ABG (arterial blood gas_O2)
_Chest X-Ray
_Sputum culture, graim stain, fungi, blood and urine culture
**Over the are of pneumonia, will see wjite opacification in the area consolidation(in one area instead all over the lung)

7/ Other types of Pneu.in Immunocompromised patient:
_PCP=pneumocystic carinii pneumonia=HIV/autoimmune Sx dod/on steroid/chemo, transplant taking the drug to block the reaction to the transplant depending on the drugs, sometimes we don't have drug to treat.
_CMV=cytomegalovirus=cause by viral pneumonia in immuno-compromised pt=>bacterial pneumonia
_Fungi:fungi pneumonia
8/Complication :
_Pleural effusion, Atelectasis, COnsolidation(localied infection), empyema, pericarditis, endocarditis, arthritis, pleurisy, lung abcesses, meningitis

9/Tx (asap)
_Antibiotic, Antiviral drugs(not work w/ bird flu)
_Specimen for sensitivity
_Fluid( 3L/day, check H. fnx)
_Oxygen therapy, med for fever/pain
_At least 1500 Kcal/day
10/Prevention(HMO):
_Flu, pneumonia vax (not cover 100%)
_Exercise habit=>keep natural resistance=>prevent aspiration
_Side lie, 30 degree, fowler position.
_Turn w/in 2h, mobility, oral care, coughing, deep breathing.
_Not over meds(pain), maintain sterial tech.
***HMO:
H=hob 30 degree
M=mobility
O=oral care(2X/day, swab in between, infuse fluid w/ syringe, brush & use suction PRN)
**Diffcult swallowing=>speech therapy=>liquid diet, start w/ thick one

Front 13

TUBERCULOSIS
1/Def:
2/Who at risk?
3/NEED?
4/Etiology:
5/Reactivation
6/ Diagnosis Procedures
7/TB tests
8/Long term Tx:
9/ Prevention

Back 13

1/Def:
_Bact. infected disease transmitted by Mycobacterium Tuberculosis.
_Incr since 1985 due to:
*HIV, immigrant student
*Deterioration of med
*Multi drugs resistance strains(MDR-TB)
*Resistance fr. not taking drugs as prescribed
*Using other substances, inadequate follow up
2/Who at risk?
*Immuno compromise
*Homeless
*Elderly, nursing homes
*CA pt.
*Prisioners
*IV drug abuse
*Asia, Africa, Latin American Immigrants
*Health care worker

3/NEED? DOT= direct observation therapy=>to protect society
4/Etiology:
*TB=communicable disease
*Aerobic, gram positive Acid Fast Bacillus
*Airborne with inhalation
*Particle small enough to reach aveoli & penetrate lung tissue
*Spread by coughing, laughing, singing, talking and sneezing.
**Primary 1st in: lung(located apesis near the pleura of lower lobe), kidney, bone, cerebral cortex congenital, lymp node, adrenal gland (can be everywhere).
**Sequence of spread:
+ronchopneumonia develop in lung tissue by TB bacilla. Many Bacilla survive macrophages=>carry to regional bronchopulmonary lymph node via lymphatic Sx=>circulating blood.
+Bacilla may spread rapidly through the body b4 the cell madiated immune response available. Most primary TB heal over in monts (forming scar or lesions_these lesion containing living bacilli, can reactivate-even after many year and cause secondary infection.
+Host has lifelong relationship with TB


5/Reactivation occur:
_When resistance lower, advanced age, immuno suppression, malnutrition, ETOH & drugs, Diabetes, renal,genetic predisposition.
6/Sign & Symptom: Cough, fatigue, anoxeria, Wt. loss, high/low grade fever, chill, sweat, dyspnea, hemoplysis, chest, pain, tightness & crackles.

7/ Diagnosis Procedures:
_Monitor TB in Cow, diary products
_TB mimics other disease, X-Ray alone not a definitive test, can occur concurrently with other pulmonary disease.
_Assess pretest result and Hx of exposure:
+Skin Test:body immune response produce Hypersensitivity 3-10 wks after exposure and once acquired-sensitivity to Tubercullino tend to persist through LIFE.
**A (+) Rnx= present of TB infection(exposed). it is not indicate whether it is active, dorminate or causing illness.
**A (-) Rnx=not exposure, or depression of cell mediated immunity as in HIV.
**Testing & reading:not wheal=>not OK=>need to repead test.Read in 48-72h. Measure bump(inderation) report in mm(>=5 mm:normal person;>10 mm:health care provider)
**2 step plan( TB VAx):1st:get base line, prevent false(negative); 2nd:between 1-2 wks fr the 1st.
+The Calcification of lungs(upper lobe and lung lesions).
+Gastric washing:
+CSF, pus from abcess
+DNA finger printing
+Sputum specimen for Dx.(need enough amount to have productive smear, 10000ml of bacteria).
+Chest X-Ray:important but not definitive because other disease can mimic TB:multinodular lymp nodes, calcification of lung's lesion occurs after many years
+Anergy Pannel Testing:(APT):failure to response to any infection. DECR immune Sx, not response to TB skin test (symptom of TB, mump, candida and others).False(-):if APT not definitive=>X-Ray, Sputum, Isolation, Wait till result fr. 3 sputum in 3 separate days.

8/Medication:
_INH (isoniazid)
_Rifampin
_Pyrazinamide
_Enthambutol or Streptomycin
***Pt start all 4 meds to prevent resistance organism becuz bacilli is difficult to kill
***Tx continue long enough to eliminate dormant bacilla
9/Long term Tx:uninterupted, chemotherapy is important=>must complete all 4 meds.
_3 options:
+DOT required( daily/2-3X per week).Enthambutor d/c if susceptibility to INH/Rifapin.Pyrazinamid d/c after 8 wks.Tx duration=6M or at least 3M after sputum convert to negative.
+Daily INH, Rifampin and pyrazinamide.Enthambutol for 2wks=>DOT(2X/wk)=>duration:6wks. Isoniazid(INH) & Rifamine DOT_2X/wk wihtin 16 wks.

+DOT(3X/wk and all 4 meds for duration of 6 months
_weekly sputum test
_Therapy not working=> at least 2 meds added. After 1 year:liver fnx test
_Not treat=>pt can't go to society.
10/ Prevention:
_N95 mask.Known TB pt.=>use negative Pressure Room. Coughing use tissue & sleave(dispose properly). Staff waer well fitting mask(thicker). If exposed: INH 300 daily for 6-12M (kill dormant bacillar)
_INH 300 mg/daily/6-12 months recommended for: newly Dx infected, (+) skin test, no symptom. Live with Tb ppl. Skin test react(abnormal chest X-Ray, inactive TB.Possitive skin test plus Diabetes, Aids, Steroid.Less than 35 yrs old, skin test react, X-ray
normal.
***VAX: BCG( bacilli calmette Guerin). Live intinuated cacine. Does not prevent/reduce chance of natural infection. Does reduce seriousness clinical symptoms
***Other ways of spreading :irritating wound(splashes on mucus membrane)

Front 14

Fungal Pulmonary Infection
1/Def:
2/2Types of fungal:
_Coccidioidomycosis:
_Histoplasmosis

Back 14

1/Regional in:
_Seriously ill
_On steroid
_Multiantibiotic
_Chemo. pt
_Most fungi pathogenis to human
_Found in skin
_Some fungal spore=>airborne=>lung=>mimic TB

2/2Types of fungal:
_Coccidioidomycosis:
+Found in desert, construction ares, digging(N.Mexico)
+60% self limitting(asymptomatic)
+40% symptomatic
_Histoplasmosis:
+Reginal fungus live in moist soil, mushroom, cellars chx house, bird dropping
+Dx by skin testing
+Disseminate in LUng, liver, CNS, Spleen, GI tract
+Tx:Amphotericin B
*fungalcidal antibiotic, Toxic
* Watch for fever, chills, vomitting, headache, DECR Renal Fnx, thrombophlebitis on site
*Premediate for N/V, histamine (DECR inflammation), antipyretic (Decr fever).
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