Internet Resources of
Interest:
Kansas Continuing Learning Project: for advanced nurse practitioners
·
Pulmonary disease occurs when the lungs are unable to
provide
adequate
oxygenation or to eliminate carbon dioxide
·
During a 24 hour period, lungs oxygenate more than 5700
liters
of blood with
more than 11,400 liters of air in the lungs
· Estimates of pulmonary disease in the U.S. annually, include over
80,000 deaths from chronic lung disease, over 5 million cases with
pulmonary disability & more than 20 million cases with pulmonary symptoms
· Cancer of the lung is the leading cause of death from cancer in the U.S.,
with the incidence in women increasing over that of men
· Asthma
· Chronic Obstructive Pulmonary Disease (Emphysema,
Chronic Bronchitis, Cystic Fibrosis)
· Pneumonia
· Lung Cancer
· Croup Syndromes (although middle airway,
is very common in young children)
· 5% of adults & 8% of children in the U. S.
· Estimated over 15 million people in the U.S. have asthma
· Incidence has increased 60% during the last decade
· Childhood exposure to damp housing, cigarette smoke &
high levels of allergens has been associated with increased risk
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
· Fourth leading cause of death in the U.S.
· Smoking accounts for >90% of the risk for COPD
· Advanced age, immunocompromise, reduced forced expiratory
volume & high alcohol intake are the greatest risk factors in
the general population
· Other risk factors include altered consciousness, smoking, underlying
lung disease, endotracheal intubation malnutrition, airway obstruction
& immobilization
· May be community acquired or nosocomial
· 80% to 90% of lung cancer is caused by smoking, with the rest
caused by air pollution, radiation, radon & industrial exposure
(such as, asbestos, arsenic, sulfur dioxide, formaldehyde, silica,
nickel, airplane glue, coal tar, textile fibers, choromethyl ethers,
chromate, vinyl chlorides)
· Incidence is highest in men >70 years old & women 50 to 60 years old
· Family history of predisposition (first degree relatives have
a 2.5 fold increase in risk
· Risk associated with passive smoking is estimated between 1.4 &
3.0 times the unexposed risk, especially in children
· Acute Laryngeotracheobronchitis (LTB) (viral croup),
more common from 3 months to 3 years, low grade fever
· Acute Spasmodic Laryngitis ( “Spasmodic,” “Midnight,”,
“Twilight,” “Allergic” Croup), more common from 1 to 4 years,
low grade or no fever
·
Acute
Epiglottitis (Supraglottitis, bacterial)
Medical Emergency,
occurs from 1 to 8 years of age, “cherry red” epiglottis,
toxic, high fever
·
Retropharyngeal
Abcess (bacterial, toxic) age 1-3 years &
variable, high fever
·
Acute Bacterial
Tracheitis (“Membranous Croup), LTB worsens,
despite therapy, age range 1 month to 6 years, toxic, high fever
· General Assessment
· Degree of distress, dyspnea or shortness of breath (SOB)
· Cyanosis of skin, nails, mucous membranes
· Evidence of chronic hypoxia, such as clubbing;
or poor growth in children
· Consider General Areas of Airway Assessment
· Upper Airway:
· Nose, mouth, pharynx, ears. (usually associated with URI)
· Adventitious sounds are loud & moist, & refer loudly
to lower airways
· Sounds are heard equally loud with stethoscope over
lung fields, throat, mouth or nasal areas
·
Middle Airway:
·
Obstruction occurs in trachea & epiglottis area
& is
usually most
evident with inspiration
·
Most common causes are croup syndromes or
foreign body
aspiration
·
Most common sign is inspiratory stridor
·
Lower Airway:
·
Adventitious sounds are softer, may be generalized
or localized to a specific area in the lung fields,
or may be
inspiratory or expiratory.
·
Breath sounds may be decreased of absent
·
Changes in fremitus, percussion & egophony may be
present
·
Retractions or
Use of Accessory Muscles:
·
Retractions may help indicate degree of respiratory
distress
·
Infants & young children may have more
sub-costal
(sub-xyphoid,
sub-sternal) & intercostal retractions
·
Older children & adults may have more suprasternal
&
supraclavicular retractions
· Nose
· Inspired air is warmed, filtered & humidified by
upper airway passages
· Obstructions may be due infection, allergy,
polyps or septal deviations
· Obstructions may be manifested by mouth breathing or snoring
· Infants are obligate nose breathers & dyspnea may
result from nasal obstruction
· Trachea & Bronchi
· Bifurcates into right & left bronchus at Angle of Louis, or 2nd rib level
·
Carina – the
area of bifurcation, where the right
bronchus is
positioned more vertically than the left bronchus
·
Right Bronchus –
is more susceptible to foreign body aspiration
·
Aspiration
Pneumonia – usually will be right lower lobe (right lung)
·
Bronchioles
·
Are no longer supported by cartilage, but are
surrounded
by smooth muscle
·
Bronchiolar smooth muscle is generally most relaxed
(open)
with inspiration
& more contracted (closed) with expiration
·
Initial spasm of smooth muscle is more apparent with
expiration,
but can progress
to the inspiratory phase
·
Expiratory wheezing is one of the first signs of
obstruction
in the
bronchioles & alveolar ducts
·
Pleural Cavity
& Pleura
·
Pleurae – are
serous membranes that cover the outer lungs
& inner rib
cage
·
Visceral pleura
– covers outer surface of each lung
·
Parietal pleura
– covers the inner portion of the rib cage & the
upper surface of the diaphram
·
Pleural fluid – lubricates
the pleurae for smooth lung movements
·
Pleural space –
potential space between visceral & parietal pleurae
·
Disruption of
pleura causes painful respirations
·
Pleurisy –
inflammation of pleurae
·
Effusion –
fluid collection between pleurae
·
Pneumothorax – air
between pleurae, causing reduction
in lung
expansion
·
Hemothorax –
blood between pleurae, causing reduction
in lung
expansion
·
Right & Left
Lungs
·
Anterior Right
Lung – Upper, middle & lower
lobes (3 lobes)
·
Anterior Left
Lung – Upper & lower lobes (2 lobes)
·
Posterior Right
& Left Lungs – each have upper & lower lobes (2 lobes)
·
Expansion & capacity the same, for all practical
purposes
· History is most diagnostic
· Obtain the patient’s baseline function, compared to the present illness
· Example: an individual with chronic bronchitis may cough &
expectorate a cup of mucous per day, and you want to find out how the
cough has changed in amount and character.
· Example: an individual with SOB may usually be able to walk one block
before experiencing SOB, and you want to find out how that has changed
· Example: Any change in chronic cough may be significant
HISTORY: QUALITY OF SYMPTOMS:
MAIN SYMPTOMS OF
PULMONARY DISEASE
· Dyspnea (shortness of breath – SOB), may be expressed as “can’t get air”
· Cough (children may vomit with cough)
· Sputum
· Hemoptysis (bloody sputum needs to be distinguished from hematomesis,
or bloody emesis)
· Chest pain – characteristics may distinquish whether the pain is pleuretic
of musculoskeletal in nature
· Wheezing
· Cyanosis
· Mucoid URI, asthma, tumors, TB, emphysema
· Mucopurulent Pneumonia
· Yellow-green, purulent Bronchiectasis, chronic bronchitis
· Rust-colored Pneumococcal pneumonia (strep. pneumoniae)
·
Red current
jelly Klebsiella
pneumonia
·
Foul odor Lung abcess
·
Pink
blood-tinged strep
or staph pneumonia
·
Gravel Bronchiolithiasis
· Pink, frothy Pulmonary edema
·
Profuse,
colorless (Bronchorrhea)
– Alveolar cell carinoma
·
Bloody Pulmonary emboli,
bronchiectasis, abcess, TB,
tumor, cardiac causes, blooding disorders
·
Examples:
·
Post nasal drip:
may have AM cough upon awakening, then clear up
· Allergies: may have itchy, watery eyes, seasonal timing
· Examples:
· Relief: hot air – cold air, laying down, sitting up, OTCs
· Exacerbate: environmental exposures, exercise, foods, OTCs,
·
Genetic &
Familial Associations
HISTORY: LIFE STYLE ISSUES
·
Job, hobbies
·
Environmental
factors
· Establish baseline of usually activities
· Exercise intolerance
· Change in cough, secondary to smoking
· Smoking history: packs/day for how many years
· Pack/Year Smoking History: Packs/day X years of smoking
COMMON TERMINOLOGY:
·
DYSPNEA:
Subjective,
history data
“SOB”
“Can’t get air”
Change in baseline?
· TACHYPNEA:
Objective, physical exam finding
Respirations faster than normal & not exercised induced
General example of resting rates:
NB 30-50/60
Child 20-30 (& not >40)
Adult 8-16/20 (& not >20s – 30s)
· HYPERVENTILATION: Person is using more air than needed (rate or volume)
Consider anxiety vs exercise
Consider brain injury vs hysterical response
Blowing off extra PCO2 can lead to respiratory alkalosis
Normal Arterial Blood Gas (ABG) PCO2: 35-45
“Over breathing” (not in response to physiologic exercise)
can lead to calcium shifting from vascular
into tissue areas, tingling & tetany
· HYPOXIA:
Decrease in blood O2 saturation level (< 90%)
>95% O2 saturation is considered good
90-95% O2 saturation is considered borderline
Normal Arterial Blood Gas (ABG) PaO2: 80-100
Lower values in the elderly > 60 years (as low as 70) are acceptable
Also look at PaCO2 (normal range = 35 – 45: average = 40)
C02 moves into the lungs better than O2, so if CO2 builds up
then hypoxia develops
·
HYPERCARBIA:
Build up of C02,
or increase in ABG PaC02
·
CHEYNE-STOKES:
Respiratory pattern of pause, gasp, deep breath, slow breathing,
pause, apnea, snore, startle, deep breath
Associated with: Sleep apnea
CNS lesion
Severe cardiopulmonary disease
Classic sleep apnea pattern: stop, pause 20 seconds
to one minute, startle, snore.
Treatment may involve positive pressure, nose devise
· KUSSMAUL:
Generally associated with Diabetic Ketoacidosis, or Ketoacidosis “sleep”
With increasing acidosis, respirations are loud, deep, regular, sighing breaths
CO2 is being blown off
(increasing CO2 levels do trigger respiration
· AGONAL:
Descriptive term, last breath, irregular, poorly moving air
· PAROXYSMAL NOCTURNAL DYSPNEA (PND):
Occurs with congestive heart failure (CHF)
Person awakes at night, after lying down for a while, with SOB or air hunger
During the day, the person is OK, the fluid is in interstitial spaces & legs swell.
At night, the fluid moves from the 3rd (interstitial) space, back into the
vascular space (over loading the heart & lungs)
Person wakes up to get air
· ORTHOPNEA:
Also occurs in CHF, but process is more severe
Just laying down causes SOB
Person may sleep in recliner, use extra pillows, or use semi-Fowler’s position
Ask about sleep position & why?
EVALUATION: PHYSICAL EXAM
·
Inspection
Look for degree of distress,
Cyanosis
Nail beds
Signs of chronic hypoxia
How well is person moving air? Using accessory muscles?
Symmetry
Chest configuration: AP:Lateral Diamter 1:2
(AP less than lateral diameter)
Infants have round chest
Elderly have increased AP diameter
Inspect for abnormalities: Barrel Chest (COPD)
Spinal deformities: Kyphosis, scoliosis
Pectus excavatum (sternum depressed)
Pectus carinatum (sternum convex) “pigeon breast”
·
Palpation
Feel for tenderness
Feel tactile fremitus: Prominent vibration or fluid wave felt with hands
over chest areas of consolidation
Use spoken voice (“99” “1-2-3”, “toy boat”
“blue moon,” vowel sounds)
Feel for symmetry/asymmetry
· Percussion Over Intercostal Spaces
· Resonance: Normal lung
· Dullness: Consolidation (fluid, mucous), pneumothorax
· Hyperresonance: Increased air pressure or trapping (emphysema,
asthma, tension pneumothorax
·
Check for
symmetry
·
Auscultation
Listen (ear & stethoscope)
Stethoscope: use a “good” stethoscope: short tubing, double lumen
meeting together (best)
Use systematic approach, side-to-side
Consider age variants:
·
Infants & young children: Good acoustics, thin chest walls
Check throat & nose for referred chest sounds
· Adults: May be difficult to hear if thick chest wall,
muscular or obese
Document if no breath sounds heard
·
Tracheal –
high pitch, loud, harsh, over trachea, inspiration longer
than expiration
·
Bronchial – high
pitch, loud, over manubrium, expiration slightly longer
than inspiration
·
Bronchovesciluar
– medium pitch/intensity, upper thorax, inspiration &
expiration equal
·
Vesciular – low
pitch, soft, over most lung fields, inspiration longer than
Expiration (prolonged
expiration indicates lower
airway obstruction)
· Bronchial Breath Sounds:
· When these louder breath sounds are heard in peripheral lung
suspect area has become “airless”
· Suspect mucous or fluid consolidation
· Bronchophony:
· Transmitted voice sounds are heard more clearly & louder than
normal, when listened to with stethoscope & patient repeating “99”
or other vowel sound
· Suspect consolidation
· Egophony:
· Transmitted voice sound of patient saying “ee” is heard as “ay,”
when listened to with stethoscope
· Suspect consolidation
· Whispered Pectoriloquy:
· Transmitted whisper, “99” or “1-2-3” is heard louder & clearer
than normal, when listened to with stethoscope
· Suspect consolidation
·
General
considerations:
·
Listen careful
·
Look for symmetry/asymmetry
·
Describe exact location of findings
·
Describe respiratory phase of positive findings
·
Rales (Crackles)
·
Wet, find crackle,
“rice crispy” sounds as alveoli snap open & shut
·
Inspiratory or expiratory
·
Indicate consolidation
·
May be decreased of absent breath sounds in middle of
consolidation,
with rales @
edges
·
Consider pneumonia
·
Wheezes
·
Squeeky, musical, senorous, hissing sounds
·
Indicates smooth muscle spasm & partial obstruction
in brochioles,
as air moves across mucous
· Initially starts expiratory, then may include inspiratory
· Consider asthma or reactive airway
· Rhonchi (Course Breath Sounds) (Senorious Wheeze)
· Course, rough sounds, of air moving over mucous
· Usually sounds more dry than wet
· Louder than rales or wheezes
· May clear with cough, gag or cry
· Consider more upper airway & bronchi involvement (URI< bronchitis)
· Consider chronic lung disease
· Rub
· Pleural friction rub, sandpaper sound, synchronous with respiration
· Pericardial friction rub (doesn’t go away when breath is held)
· Friction & inflammation of pleural space or pleural effusion
· May be dull to percussion
·
Decreased Breath
Sounds
· Air is not moving
· Consider consolidation, pneumonia
· Consider asthma
· Consider pneumothorax (trauma or spontaneous, ie. ruptured blebs)
·
Stridor (Major
sign of Croup)
·
Always inspiratory
·
In trachea & epiglottis area (indicates
obstructioin)
·
Course, high pitched
·
May have dry, brassy cough
·
Hoarseness
·
Consider croup syndromes
·
Consider aspiration of foreign body
·
Common in young children
· Tachypnea: continuous respiratory rate above 40, beyond newborn period
· Dyspnea & labored breathing
· Retractions
· Inspiratory lag of chest may develop into “see-saw” respirations in infants
· Nasal flaring
· Expiratory grunt
· Inspiratory stridor
· Anxiety & air hunger
· Drooling
· Dysphagia (difficulty or inability to swallow)
· Dyspphonia (difficulty or inability to speak)
· Inability to cough
· Increased agitation, frantic, unable to sleep
· Tripod or upright position
· “Sniff “ Position
· Cyanosis may be a late sign, except in congenital heart disease
DIFFERENTIAL DIAGNOSIS
·
Normal
What is different, from baseline, for that person?
· Pneumonia
Acute respiratory infection with inflammation of lung parenchyma,
including interstitial tissue & alveolar spaces
How well is that person moving air?
· Viral
· Bacterial
· Atypical
· Age Specific
VIRAL PNEUMONIA
·
Cough
Usually non-productive, dry
· Sputum
May be mucoid, clear or white
· Illness
May be ill for days, vs hours
Fever low grade, no spike, comes & goes
No consolidation
·
Chest X-ray
May be clear to diffuse, & may not correlate with clinical picture
·
Cough
Usually productive
· Sputum
Colored, purulent, thick, yellow, green, rust colored (strep. peumonia)
· Illness
Progresses quickly, hours vs days
Fever spikes, with high fever
May have viral prodrome, but secondary bacterial infection occurs
Consolidation: rales, decreased breath sounds, rubs
May affect one lung or one lobe; check for symmetry
Dullness to percussion over consolidation areas
· X-ray
May lag behind clinical course
Consolidation may block out h eart
· Due to atypical organisms
· Most commonly mycoplasma pneumonia, especially in young
adult population
· Shows clinical picture of viral & bacterial combination
· May be difficult to culture
· Illness
Fever, usually low grade, chills, dry cough
“Walking pneumonia”
· X-Ray
Normal to diffuse
· Neonatal
· Infants
· Children 5 to 10 years of age
· Children & Adults, 5 to 40 years
· Usually bacterial: E. coli, A & B Strep., S. Aereus, pseudomonas, chlamydia
· Virulent beta Hemolytic strep: “Baby Killer” (Prenatal treatment usually done)
·
Under 5 years: Usually viral, approximately 80%
·
Usually can be treated as out-patients, unless allergic
·
Bacterial cause: Severe Illness
Most common bacteria: Strep. pneumonia, Haemophilus influenzae
First line treament: Amoxicillin
Rare: Staph aureus
PNEUMONIA: CHILDREN 5 TO 10 YEARS OF AGE
· Most are viral
· Extension of URI
·
Most are viral
·
Atypical
microorganisms: mycoplasma,
chlamydia
·
Bacterial: S. pneumonia (most commone) H. flu
·
Legionella: more common after 40 years of age
·
Treatment for
mycoplasma: Macrolyte antibiotic
(erythromycin, biaxin, zithromax)
PNEUMONIA: ASPIRATION
·
Decreased level of consciousness
·
Cerebral Vascular Accident
·
Drugs
·
Alcoholics
·
RRL (right lower lobe) aspiration may occur at night,
from mouth
& stomach secretions. Acid reflux may cause pneumonitis
·
Organisms: tend to be s. pneumo, baceriodes, gram
negatives,
mouth organisms
PNEUMONIA: HIV
·
Organisms: pneumocystis carcinii, s. pneumo, tuberculosis,
histoplasmosis,
& others
·
Association: >TB associated with HIV
·
Most common age
group: 15 to 20 years if age &
early
to mid-twenties
· Chest X-ray
· WBC
Bacterial Infection:
WBC elevation, with shift to the left or increase in percentage
of neutrophils & bands
Viral Infection:
WBC in normal range, (“right shift”), with increase in lymphocytes
· Sputum cultures
· Inflammation of tracheobronchial tree
· Increased secretions
·
Cough is hallmark sign: may be dry & hacky, or moist & product
·
Usually viral
·
Lungs are clear, with no consolidation
· Inflammation of bronchioles resulting in small airway obstruction
· Clinical Picture: Wheezing, cough, diffuse crackles (rales) & rhonchi
· Usually viral
· Adolescents & adults – most are viral or atypical organisms
BRONCHIOLOTIS IN
CHILDREN UNDER 5 YEARS
CALLED
LARYNGOTRACHEOBRONCHITIS IN VERY YOUNG CHILD
·
Increased wheezing
·
Under 2 years of age:
·
Usually in winter
·
History of URI
·
90% are to RSV
(Respiratory Syncytial Virus)
Secretions are thick with RSV
·
May be due to other viruses, such as adenovirus
or parainfluenza
·
Under 6 weeks of age:
Potentially life threatening
· Usually viral:
· No > in WBC, neutrophils, seg or bands
· Lymphocytes are increased
· Negative chest x-ray
· Stress can produce some WBC left shift
· Middle Airway Infection
· Croup LTB
· Spasmodic Croup
· Epiglottitis
· Tracheitis
· Retropharyngeal Abcess
·
IMPORTANT
DIFFERENTIAL DIAGNOSIS:
CROUP LTB VS ACUTE EPIGLOTTITIS
(rapid fever spike)
CROUP: LTB
· Peak: 6 months to 2 years
· Viral
· Mild fever
· Inspiratory stridor
· Barking cough
· Peak: 1 to 4 yours
· Unknown etiology: may have mild URI history
· Sudden occurrence
· Low grade or no fever
· Inspiratory stridor
·
MEDICAL
EMERGENCY
·
Peak: 1 to 8
years
·
Bacterial
·
Rapid onset
·
High fever
·
Toxic
·
“Cherry Red” epiglottis
·
Severe respiratory distress
·
Potential for airway obstruction
·
Do not examine throat,
unless prepared to intubate
·
Inflammation of trachea
·
LBT worsens, in spite of therapy
·
High fever
·
Toxic
·
Purulent secretions
· Abcess of pharyngeal area
· Potential for airway obstruction
· High fever
· Onset more gradual
·
Peak: 1 to 3
years
* A croup
syndrome chart is included on the following page for your reference.
CROUP
SYNDROMES
|
|
Acute
Epiglottitis |
Retropharyngeal
|
Acute
LTB |
Acute
Bacterial |
Acute
Spasmodic |
|
|
|
Abscess |
Laryngeotracheobronchitits |
Tracheitis |
Laryngitis |
|
|
|
|
|
|
|
|
Synonyms |
Supraglottitis |
None |
Viral
Croup |
Membranous
|
Spasmodic
Croup |
|
|
|
|
Subglottic
laryngitis |
Croup |
“Midnight”
Croup |
|
|
|
|
|
|
“Twilight”
Croup |
|
|
|
|
|
|
“Allergic”
Croup |
|
|
|
|
|
|
|
|
Age |
1
- 8 years |
1
- 3 years: variable |
3
months -3 years |
1
month - 6 years |
1-
4 years |
|
|
Usually
> 2 years |
|
Peak
6 months - 2 years |
|
|
|
|
|
|
|
|
|
|
Etiology |
Bacteria |
Bacteria |
Virus |
Bacteria |
Unknown |
|
|
H.
Influenzae B |
Strep.
A |
Parainfluenza |
S.
aureus |
Virus
- Allergy |
|
|
S.
Pneumococci |
S.
aureus |
Influenza |
H.
Influenzae |
|
|
|
|
|
|
|
|
|
|
|
Anaerobics |
Respiratory
Syncycial Virus |
Strep.
A |
|
|
|
|
|
|
(RSV) |
|
|
|
|
|
|
|
|
|
Onset |
Rapid |
Gradual |
Gradual |
LTB
worsens |
Sudden,
usually |
|
|
|
|
|
despite
therapy |
at
night |
|
|
|
|
|
|
|
|
Signs
& |
High
fever |
High
fever |
Mild
fever |
High
fever |
No
or low fever |
|
Symptoms |
Toxic |
Toxic |
Non-toxic |
Toxic |
Inspiratory
stridor |
|
* |
Inspiratory
stridor |
Acute
pharyngitis |
URI |
Stridor |
“Barking,” “Brassy” |
|
|
Cough
rare |
Drooling |
Inspiratory
stridor |
Croupy
cough |
“Seal
- like” cough |
|
|
Drooling |
Respiratory
distress |
“Barking,”
“Brassy” |
Purulent,
thick |
May
have history of |
|
|
Dysphagia |
Dysphonia |
“Seal
- like cough |
secretions
obstruct |
mild
URI |
|
|
Dysphonia |
Neck
hypertension |
Hoarseness |
airway |
|
|
|
Agitation |
|
Dyspnea |
|
|
|
|
|
|
|
|
|
|
|
MEDICAL |
|
|
|
|
|
|
EMERGENCY |
|
|
|
|
|
|
---potential
airway |
|
|
|
|
|
|
obstruction
in first |
|
|
|
|
|
|
6
- 12 hours |
|
|
|
|
|
|
“Cherry
Red,” |
|
|
|
|
|
|
edematous
epiglottis |
|
|
|
|
|
|
|
|
|
|
|
|
Treatment |
Protect
Airway -- |
Protect
Airway - |
At-home
therapy: |
Protect
Airway - |
Warm
or cool mist |
|
** |
endotracheal
tube or |
IV antibiotics - |
Mist humidity |
Intubation & |
(Warm
steam from hot |
|
*** |
tracheostomy |
Penicillin, Oxacillin |
Antipyretics |
frequent
suctioning |
shower
in closed |
|
|
IV
antibiotics |
Cefuroxime |
Oral
hydration |
IV
antibiotics |
bathroom) |
|
|
Cephalosporins: |
Surgical
incision |
Observation |
Penicillin |
Reassurance |
|
|
Ceftriaxone |
&
drainage |
In-hospital
therapy: |
Cephalosporins |
If no improvement, |
|
|
Cefotaxime |
Hospitalization |
Mist humidity |
Hospitalization
- ICU |
Racemic
epinephrine |
|
|
IV
fluids |
Otolaryngology |
Racemic epinephrine |
|
aerosol may help |
|
|
Monitoring |
consult |
O2 |
|
|
|
|
Humidity
& O2 |
|
Steroids
(short course) |
|
|
|
|
Hospitalization
- ICU |
|
Intubation if severe |
|
|
* Examination of posterior pharynx can be dangerous and
may precipitate airway obstruction in the toxic patient with stridor,
especially if acute epiglottis is suspected.
Throat inspection should be attempted only when immediate intubation can
be performed if needed.
** Refer to physician if
significant fever is associated with stridor, airway obstruction is
threatened, if the clinical condition is worsening despite treatment, if croup
is a recurrent problem or if infant is under 6 months of age.
*** Do not leave patient unattended. Do not agitate. Avoid invasive procedures if possible. Allow patient to sit upright on parent’s lap. Do provide a quiet reassuring atmosphere.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE:
COPD
·
Asthma
· Wheezes, delayed expiration, use of accessory muscles
· Attacks may be triggered by infection or environmental factors
·
Emphysema
· Increased AP chest diameter
· Over inflated alveoli, with trapped air
· Pursed lips are a serious sign
& attempt to get air out of lungs during expiration
· Hyperresonant to percussion
· High percentage have smoking history
· Chronic Bronchitis
· Most are smokers & also have emphysema
· Get baseline sputum history,
as may cupfuls of sputum every day for many years
· Collapsed lung: airways collapse on each other
· Decreased breath sounds
· Painful, short breaths
· May occur post-operatively
· May occur from ruptured blebs, as with emphysema
· May occur spontaneously, more commonly in tall, thin young adult males
· History of night sweats
· Chills
· Sputum, chronic
· Rule out exposure to TB
· History of sweats
· Chills
· Immunocompromised
· Previous infections
· History of alcoholism
· Classic X-ray findings for consolidation
·
Rales
·
Orthopnea
·
PND
·
Rule out CHF
· Primary Cancer, usually smokers
· Change in cough
· Blood in sputum: late change
· SOB
· X-ray evidence non-predictive & changes show up too late in disease
· Metastasis
· Weight loss
· SOB
· Most common metastatic areas: breast, colon & prostate
· Air replaces lung tissue: minimal to massive
· Acute SOB
· Absent breath sounds
· Tension pneumothorax: one way valve action increases air in pleural space
& increases pressure on heart, decreased flood flow & blood pressure.
May have mediastinal shift
· Hyperresonant to percussion if tension pneumothorax
· Most common incidence: chronic smokers, emphysem, young tall,
thin adult males, trauma
· Rule out trauma
· Dull to percussion
· Absent breath sounds
ADULT RESPIRATORY DISTRESS SYNDOME
· Patient is severely ill, with 70% mortality rate
· May be called “shock lung”
· Due a variety of causes, such as pneumonia, trauma, aspiration,
gram negative sepsis
· Patient becomes ventilator dependent
·
Result of prematurity
·
Before 32 weeks gestational age, lack of surfactin
prevents
adaequate alvelar expansion
· Due to inflammation of pleural membranes
· May have viral or trauma etiology,
such as rib fracture, blow to chest, inflammation following pneumonia
· Signs: Splinting & not wanting to change positions or take deep breaths
May have pleural friction rub
Pain is sharp, knife-like & gets worse when chest is pushed on
·
History of trauma
·
Over-use
·
Check \e point tenderness in specific areas
·
Cardiac pain is more diffuse & radiates
·
Fluid in pleural space, coming from lungs draining into
pleura
·
Fluid is gravity dependent
·
Seen in severe
pulmonary edema, cancer, trauma