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53 Cards in this Set
- Front
- Back
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Name some common upper respiratory infections
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– Oronasopharynx
-- Upper Respiratory Infections, sinusitis, HSV gingivostomatitis, thrush – Pharynx --Pharyngitis, tonsillitis – Larynx and Epiglottis -- Croup, epiglottitis – Upper trachea |
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Name some common LOWER respiratory infections
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– Lower trachea
-- Tracheitis – Lungs, (bronchi, bronchioles, alveoli) --Pneumonia –-- Bacterial-S. pneumoniae, P. cepacia, M. pneumoniae –-- Viral-Respiratory Syncytial Virus (RSV), Influenza –-- (Bronchitis is usually viral) - Asthma –- Inflammation leading to wheezing/asthma –- Can be precipitated by allergy or infection |
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Respiratory Assessment
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- Rate
–- Tachypnea --- Heart or lung disease, lung infections, anemia –- Bradypnea --- Diabetic Keto Acidosis, liver failure, respiratory failure, ICP - Rhythm - Easy or Labored –- Dyspnea, orthopnea, wheezing, nasal flaring, grunting, retractions - Depth –- Hypopnea-shallow and slow –- Hyperpnea-increased depth and rate |
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Respiratory TESTING
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- Pulmonary Function Tests - non-invasive
–- Vital capacity (VC) –- Forced vital capacity (FVC) –- Tidal volume (TV) –- **Peak expiratory flow rate (PEFR) - Pulse oxymetry, arterial blood gases (ABGs), apnea/bradycardia monitor (A/B) - Chest X-ray, CT scan, MRI, bronchoscopy |
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Bronchoscopy
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- Diagnostic or therapeutic (foreign body)
- Pre-procedure –- Sedative / atropine –-PT, PTT if biopsy being done - Post-procedure –- Suction, postural drainage –- Fluids after gag/swallowing returns –- Complications: hemorrhage, respiratory distress |
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Respiratory Assessment
Infection Considerations |
- Symptoms
--Fever, cervical lymphadenopathy, sputum, erythema, bad breath – Age -- Maternal antibody protection -- RSV, M. pneumoniae -- Increased exposure with day care and school – Size -- Edema + secretions = bigger problems for small airways – Decreased Resistance (ex. Cystic Fibrosis, AIDS, SLE) -- Immune deficiencies -- Malnutrition, anemia, fatigue – Weakened Defenses -- Allergies, asthma, CF –- Seasons - RSV (August Sept), Influenza (Winter), M. pneumonia (Fall) - Cough –- Timing, nature, frequency, character - Chest pain - Cyanosis |
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Addiitional Respiratory Considerations
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- Infants
–- Obligate nose breathers –- Small airways –- Large tongues - Older children –- Prominent adenoids and tonsils |
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Respiratory Emergencies
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– Upper airway obstruction - stridor
-- Epiglottitis -- Croup -- Foreign body aspiration – Lower airways - cough and wheeze -- Asthma --Hypersensitivity reactions – Can progress to respiratory distress |
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Define Respiratory Distress
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- Respiratory system is not able to keep up with the oxygen and gas exchange needs of the patient.
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Respiratory Distress SYMPTOMS
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- Tachypnea
–- >60 infants - Nasal flaring –- With each breath - Retractions –- Substernal, intercostal - Cyanosis –- Decreasing SaO2 - Accessory Muscle Use –-Neck - Grunting –- Collapse of vocal cords with each breath - Mental status or speech changes –- Restlessness –- Confusion |
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Respiratory Distress Treatment
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- Immediate respiratory support
- Worry about the cause once more stable –- Oxygen –- Medications --- Albuterol, epinephrine - If unable to stabilize, may need –- Ventilation –- Intubation --- Nasopharyngeal or endotracheal airway --- Tracheostomy |
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Definition of Respiratory Failure
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• A condition resulting in failure of the lungs to function properly. This causes severe hypoxemia and/or hypercapnia.
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Etiology of Respiratory Failure
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– Gas exchange impairment
– Ventilation impairment |
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Respiratory Failure GAS EXCHANGE PROBLEMS
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– Hypoxemia
-- RDS -- High altitudes -- Lung disease -- Cardiac shunting |
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Respiratory Failure VENTILATION IMPAIRMENT
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– Hypercapnia
-- Obstructive lung disease -- Respiratory center fails to drive breathing -- Muscles don’t allow chest expansion |
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Causes of Respiratory Failure
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- Airway obstruction
–- Foreign body, cystic fibrosis, secretions –- Asthma, anaphylaxis - Lung disease –-Severe pneumonia, asthma, cystic fibrosis, pulmonary edema, cardiac defects causing shunting from the lungs, radiation therapy - Weakness affecting breathing –- Drugs, severe obesity, sleep apnea - Muscle weakness –- Muscular Dystrophy, spinal cord injury - Abnormal chest wall – Injury, severe pectus excavatum, severe scoliosis |
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Respiratory Failure SYMPTOMS
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– Restlessness (can be missed) (EARLIEST SIGN)
- Cyanosis, arrythmia - Tachypnea, tachycardia, shortness of breath - Mental confusion - Headache - Gasping for breath -- Increased used of neck muscles - Coma |
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Respiratory Failure MANAGEMENT
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- Immediate respiratory support with O2
- Determine, treat underlying condition –- Inspired humidity to decrease secretions ---Suctioning, postural drainage – Corticosteroids for airway edema – *Epinephrine (COMMON DRUG USED FOR RESP. FAILURE) – Intubation |
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Medical use for Epinephrine for Resp. Failure
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- Be careful
–- 1:1000 = 1 mg/ml used SC (Works faster than IV, ironically enough) –- 1:10000= 0.1 mg/ml used IV - Bronchodilator -- 1:1000 (1mg epinephrine per ml) -- 0.01ml/kg/dose SC –-- maximum single dose 0.5 ml/dose --- Repeat q 15 minutes for 3-4 doses –--Can give q 4 h |
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Epinepherine Hypersensitivity Reactions
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– Anaphylaxis from allergic reactions or illness
-- 1:1000 -- 0.01 mg/kg/dose IM or SC -- 0.5mg maximum dose -- Can repeat q 20 minutes- 4 hours - Epi-Pen -- > 30 kg (0.3mg per dose) – Epi Pen Jr --< 30 kg (0.15mg per dose) |
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What to monitor when Epi is given
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For hypertension and tachycardia, EKG
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Naloxone Use for Resp. Problems
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- Opiate intoxication antidote
-- < 20 kg - 0.1 mg/kg/dose -- > 20 kg or > 5-years - 2 mg/ dose -- Very short acting, repeat q 2-3 minutes -- Reevaluate diagnosis if no response after 10 mg -- IM, IV, SC, ETT –Side Effects --N/V, diaphoresis, tachycardia, hypertension, tremors |
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Asthma Pathophysiology
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- Chronic, reversible inflammatory airway disorder, involving mast cells, leukotrienes, eosinophils, characterized by
–- Airflow obstruction --- Bronchospasm --- Mucosal edema --- Increased mucus production and airway remodeling –- Airway hyperresponsiveness --- Sensitivity to allergens --- Often also have eczema, allergic rhinitis |
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Asthma MANIFESTATIONS
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- Cough
–- Earliest sign, especially nocturnal –- Dry and hacky, or productive - Tachypnea - Expiratory wheezing -- Retractions - Restlessness, anxiety, sweating - Hunched-over, panting phrases, fatigue |
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Asthma Diagnostic Tests
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- Pulmonary Function Tests
–- Show signs of airway obstruction –- Low-normal or decreased vital capacity –- Increased total lung and residual capacities - Bronchial challenge testing - Serum IgE levels or eosinophilia - Chest x-ray –- Hyperinflation of lungs, atelectasis |
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Four Grades of Asthma
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- Intermittent
–- Symptoms twice a week or less –- Pulmonary function > 80% normal - Mild persistent –- Symptoms > twice a week, but not daily –- Pulmonary function > 80% normal - Moderate persistent –- Symptoms and bronchodilator use daily –- Pulmonary function 60-80% normal - Severe persistent –- Symtoms continuous, activity limitations –- Pulmonary function < 60% normal |
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Asthma MANAGEMENT
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- Prevention
–- Identifying and avoiding triggers ---Persistent wheezing can damage lungs -- Dust mites, animal dander, mold, cold air, foods –- Avoiding sick contacts –- Annual influenza immunization - Desensitization –-If stimuli can’t be avoided - Medications –- Based on severity of asthma –- Use aided by results of Peak Flow Meter (p. 822) |
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Asthma Care Devices
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- Spacer
- Nebulizer - Read use of Peak Flow Meter p. 822 - Read interpreting peak flow rates p. 815 Read use of MDI p. 822 |
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Respiratory MEDICATIONS
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- Rescue Medications
–- To treat acute symptoms and exacerbations --- Short acting ß2-Agonists --- Oral or IV corticosteroids - Long-Term Controller Medications (Prevention) –- To achieve and maintain control of inflammation --- Inhaled corticosteroids, long acting ß2-Agonists, --- Inhaled NSAIDs, oral leukotriene modifiers |
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Short acting ß2-Agonists for ‘Rescue’
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- Dilate smooth muscle, decreasing spasms
- Should only be taken up to four times daily - Side effects –- Tremors, tachycardia, insomnia, dry mouth, hypertension - Albuterol –- Nebulizer or MDI (spacer with MDI) –- Oral not effective - Xopenex (Levalbuterol HCl) –- Nebulizer only –-Less cardiac side effects than Albuterol –- Can use as young as 2-years |
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Peak Flow Meter
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Blow into it, not inhale into it
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Corticosteroids for ‘Rescue’
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- Decrease inflammation to treat airflow obstruction
- Lowest dose to avoid side effects –- Osteoporosis, immune problems, hypertension - Prednisolone (Orapred®, Pediapred®) –- 3-10 day ‘bursts’ orally –- 1-2 mg/kg/day divided q day to q 12 hours –- Maximum 60 mg per day –- Do not take with grapefruit juice –- Orapred is 3 times more concentrated than Pediapred - Solumedrol –- Given IV for hospitalized patients |
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Long-Acting ß2 Agonists (LABA) For Control or Prevention
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- Long-acting: Not for acute asthma
–- Salmeterol: Serevent® DPI ---1 puff q12h in patients > 4-years --- Also treats exercise induced asthma (EIA) –-Formoterol: Foradil® DPI ---Same as Salmeterol but must be > 5-years - Combination with steroid –- Fluticasone/Salmeterol: Advair® DPI --- 250mcg/50mcg or 100mcg/50mcg --- Wash mouth to decrease risk of oral candidiasis - Tell patient to d/c ‘rescue’ bronchodilator –- Restart only if acute exacerbation occurs |
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Anti-inflammatory Agents for Control
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- Inhaled Corticosteroids
–- ‘Prevention of symptoms and suppression, control and reversal of inflammation’ (p. 817) --- Flovent® –--- Only by Discus inhaler --- Pulmicort® –----By inhalation or Turbuhaler® - Cromolyn (Intal®) –- NSAID, stabilizes mast cell membrane and inhibits inflammatory mediator release |
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Leukotriene Modifiers for Control
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- Leukotrine Modifier
–- Prevention of bonchospasm, mucosal edema and increased secretions caused by the leukotrienes –- Montekulast (Singulair®) ---Drug of choice ---Oral, once daily --- No serious side effects or drug interactions –- Zileuton and Zafirlukast --- Dosed 2-4 times per day ---Side effects |
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Exercise Induced Asthma (EIA)
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– Acute, self limiting
-- Onset 5-10 minutes after exercise -- Resolves in 20-30 minutes -- More common with endurance sports –---Except swimming – Avoidance of exercise unnecessary -- Fear of exacerbation unfounded --Socialization important -- Long-Acting ß2 Agonists used --- Serevent® or Foradil® |
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Status Asthmaticus
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– Increasing distress despite treatment
–- Therapy to --- Improve ventilation –--- Short acting ß2-Agonists and corticosteroids --- Re-hydrate –---Fluids given at maintenance rate (pulmonary edema) ---If not improving, epinephrine is used –--- 0.01ml/kg SC not to exceed 0.3ml --- Frequent monitoring of O2, ABGs and electrolytes to assess improvement |
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Asthma Education
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– Equipment
-- Peak flow meter, nebulizers, MDI and other inhalers, spacers – Symptoms -- Asthma action plan -- Green, yellow, red zone and what to do – Chronic steroid use --Risk of oral candidiasis with inhaled steroids -- decreases risk of death from asthma d/t better control -- Need to be weaned from long term oral steroids prior to starting inhaled steroids -- Linear growth needs to be monitored every 3-6 months |
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Cystic Fibrosis
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- Autosomal recessive disorder of exocrine glands
- Defective CFTR gene –- decreased secretion of chloride, increased re-absorption of sodium and water in epithelial cells –- Results in less hydrated mucus ---Bacteria stick to it causing infection and inflammation --- Causes thick secretions in the pancreas and in the respiratory, gastrointestinal, and reproductive tracts --- Hard for the body to deal with and clear |
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Cystic Fibrosis Respiratory Effects
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- Lungs normal at birth
- Recurrent infections with inflammation and viscous mucus –- Difficult to expectorate, increased coughing --- Daily CPT and inhaled antibiotics –- Medium for bacterial growth, pneumonia --- P. auriginosa, B. cepacia, S. aurues - Structural damage of lungs - Poor gas exchange –- Chronic hypoxia with clubbing, hypercapnia –- Pulmonary hypertension and respiratory failure can result - End stage lung disease and death –- Life expectancy is ~ 35-years –- Males live longer |
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Cystic Fibrosis GASTROINTESTINAL EFFECTS
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- CFRT defect water transport to gut
–- Meconium ileus at birth can result –- Distal intestinal obstruction syndrome (DIOS) can occur in older patients - Pancreatic Insufficiency –- decreased intestinal absorption - Plus, problems with GI tract caused by CF –- Can cause fecal impaction or intussusception –- Adhesions can cause obstruction -- Resection of distal ileum further decreases absorption |
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Cystic Fibrosis Pancreatic Insufficiency (PI)
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- Pancreatic enzymes can’t reach gut or work
–- Plugging of pancreatic ducts ---Thick secretions –-Precipitated proteins - PI presentation –- Greasy, bulky stools –- FTT, poor weight gain –- Malabsorption of vitamins A,D,E,K - IDDM |
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Cystic Fibrosis HEPATIC EFFECTS
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- CFTR defect leads to
–- Viscous bile –- Clogged bile ducts --- 15% CF patients have gallstones –- If extensive, can lead to obstructive cirrhosis |
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Cystic Fibrosis FEMALE REPRODUCTIVE EFFECTS
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- Females
–- Fertility maintained, but decreased --- Viscous cervical secretions may block sperm --- Amenorrhea 2° to severe nutritional or pulmonary problems --- Secondary sex characteristics often delayed |
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Cystic Fibrosis MALE REPRODUCTIVE EFFECTS
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- Males
–- Vas deferens can be absent –- Undescended testicles can occur |
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Cystic Fibrosis DIAGNOSTIC TESTS
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– Qualitative pilocarpine iontophoresis test
-- Measurement of chloride in the skin -- < 40 mg is negative --- Don’t need to re-test negative unless they have symptoms consistent with Cystic Fibrosis such as ----Family history of CF, parent is a carrier ----Bulky, foul stools, FTT, recurrent respiratory infections ---> 60 is positive but must be repeated –---- Other disorders can cause a positive test – Newborn Screening -- Added to the testing September 17, 2007 |
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Cystic Fibrosis MANAGEMENT
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- Multidisciplinary approach
–- CF clinic visit recommended every 2-3 months ---Monitoring of growth and development ---Assessment of lung function with PFTs and pulse oxymetry as well as treatment –---Pulmonary toileting with CPT or Vest bid-qid –----Antibiotics, bronchodilators and airway clearance --- Assessment of GI tract for malabsorption symptoms –---Pancreatic enzyme administration --- Monitoring for complications of treatment --- Assessment of psychosocial issues |
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Cystic Fibrosis Respiratory Management
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- Chest physiotherapy daily
- Mucous clearance devices - Medications –- Bronchodilators –- Oxygen therapy –- Pulmozyme aerosol to viscosity –- Antibioitcs require much higher doses --- Tobramycin, Gentamycin |
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Cystic Fibrosis POSTRURAL DRAINAGE
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- Removes excess fluid and mucus
- Chronic lung disease –- Asthma, Cystic Fibrosis (CF) –-1-2 hours after meals --- decreases vomiting - More effective after aerosol or inhalation treatment - Contraindicated: ---Pulmonary hemorrhage, pulmonary embolus, ICP, osteogenesis imperfecta |
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Postural Drainage AEROSOL TREATMENT
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- Bronchodilators, steroids, antibiotics
–- Direct distribution into airway –- Reduces amt of med needed –- Avoids systemic S/E - Nursing Implications –- Auscultate lungs, assess response, observe for S/E |
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Cystic Fibrosis GASTROINTESTINAL MANAGEMENT
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- Pancreatic enzymes with meals
–- Creon, Pancrease, Ultrase - High calorie, high fat diet plus snacks –- G-tube feeds for adequate calories - Replace ADEK daily |
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Cystic Fibrosis Issues
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- Psychological stress
–- Dependence / Independence struggles –-Parental guilt --- Sibling testing, further children, carrier state –- Impending death of child/self –- Support groups |
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Cystic Fibrosis Education
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- Chest physiotherapy and postural drainage
- Proper caloric intake and diet - Correct use and cleaning of equipment - Early signs of infection, complications - When to seek medical care |
