Welcome to the Respiratory Module Part II 

 

 

Respiratory  Module Contents/Index Part II

Emphysema
Respiratory Drugs
Pneumonia
Pneumocystis Carinii

Return to the Respiratory Module Part I

 

  Emphysema

Definition: Abnormal and Permanent enlargement of gas exchange airways (acini),
accompanied by the  destruction of alveolar walls.
If we could see inside the lungs,  we would see permanent stretching and enlargement of the
alveoli.

     Acinus:
A unit of 3 things
1. Respiratory Bronchioles
2. Alveolar Ducts
3. Alveoli
These together make up the gas exchange airway system

Recall from anatomy that the actual gas exchange takes place in the respiratory bronchioles, alveolar ducts and alveoli.
Your book calls these the Acini. (plural of acinus. I often  use the word alveoli but in the strict sense, I mean the acini).
 

                      
www.lung.ca/pneumonia

Pathophysiology:
Scenario:
Adam  (mentioned in Module I) is now 66 years old. He has been on O2 at home for 6 years. You occasionally see him at the grocery store, walking slowly, carrying his oxygen tank along with him. His wife is with him to do the lifting and the heavy work. Adam may have a variety of diagnoses but a very good bet is that he has emphysema. He walks slowly and appears SOB. He tells  you that he rarely goes out of the house as it is just too much effort. Mostly he sits in his chair and reads or watches TV. His wife is with him and she secretly tells  you that she is getting worn out as she has "to do everything at home these days".
This is what an RN should realize is occurring in Adam's lungs if he has emphysema:

bulletPermanent stretching/ enlargement of his alveoli
bulletLoss of elasticity/recoil with abnormal dilation of the air spaces
bulletAlveolar walls are destroyed and the connective tissue support in the lower airways breaks down.
bulletHyperinflation  occurs. Lung sacs are permanently over inflated.
bulletAppears to be the end stage of a process that has progressed slowly for years
bulletIrreversible
bulletObstruction relates to actual changes in the lung tissue itself, (verses mucous and inflammation of
chronic bronchitis.)

Ponder:
When did this disease process begin for Adam?
At what point does a client become aware that he/she has emphysema?
Early or late in the disease state?
If a friend  with emphysema seems to be coughing productively, month after month after month, what additional diagnoses might you suspect?

2 Major Causes  of Emphysema:
1) Major  cause is :__________________What percent of the time?
2) Deficiency of alpha antitrypsin (we normally have enough of this enzyme).
   
Enzymes called proteases, have the potential to destroy the walls and elasticity of the alveoli.
   Normally the lung is protected from this process by an anti protease enzyme called  alpha 1 antitrypsin.
   In emphysema (1-2% of cases) there is a genetic imbalance between the two enzymes.
   Deficiency of alpha antitrypsin --> destruction of the alveoli walls.
   This is a genetic disorder - an inherited recessive trait so both parents have to have the  defective gene.
   It is particularly important that these persons not smoke. Why?
    

Manifestations of Emphysema:              (7 of the more common ones)

bullet1) Dyspnea: Have you ever seen people with COPD huff and puff with any activity? 
Realize that it can be a major focus just to get adequate air. 
Sometimes they can't even complete a sentence without having to stop mid sentence and catch their breath.
(Watch for this in the clinical setting)
 
bullet2) Orthopnea:  The preferred position is a 'sitting up straight' position which stabilizes  chest structures and allows maximum  chest  expansion.  Many of you have seen these clients sitting on the edge of the bed with their arms forward on the bedside table for support.
Now, each of you -  try bending over in your chair and  see how much harder it is to breathe? This is why these people insist of being upright. What happens when we try to help them lie flat?
 
bullet3) Increased use of accessory muscles: Air flow 'IN' is still possible. Thus the person will work  hard to breathe. You will see the accessory muscles hard at work. (This is easy to see in a clinical setting. Watch for it. Look at the chest, abdominal and neck muscles moving  visibly with each breath).
During inspiration, the airways are pulled open, allowing air to move past any obstruction.
 
bullet4) Prolonged Expiration : The airway has collapsed or narrowed and this traps the air in the distal spaces.                                        Don't miss Figure 26 - 11. The picture tells it all!
 It will require a focused effort to get the air out.
 We teach these clients to breathe out through pursed lips (take a deep breath in and then  let it out very slowly over 6- 8 seconds, through lips that are almost closed. Try this - it  works by slowing expiration and thus preventing/decreasing the collapse of the lung air  sacs and airways.

                                   

 

bullet5) Struggle to Maintain Normal  Arterial Blood Gas Values:
(This section is long-  It's IMPORTANT!)

Eventually the client will tire and decompensate --> hypercapnia & Hypoxemia.
The client eventually, over years, becomes exhausted.

                   
Lets draw a sample of arterial blood from an artery (Ouch!)....             
and then lets:
Put an O2 sat meter on a finger  (No Pain - wow) and see how saturated the red blood cells are with O2 as they travel through the finger.
Lets look at the values..


www.cob.org/fire

NORMAL Value

IN EMPHYSEMA

Arterial 02       =   80- 100 PO2  is below 80, often down to 50 -60
O2 saturation  =  96 - 100 % O2 saturation hovers about 90 as a baseline
PCO2                =   35 - 45 PCO2 = > 45
HCO3                = 22-26 (variable depending upon compensation)

 
Through the use of  an INC breathing rate, and use of accessory muscles, emphysema clients can initially compensate and maintain near normal gas levels.
We call these persons "Pink Puffers". (These are the clients who look pretty good when you assess them.
They are working hard to breathe. They hold their O2 sats above 90 % and seem to be breathing fairly well at this stage.
What will happen if they keep on smoking?)

As the disease progresses, and as we see them work harder to breathe --> decompensation occurs and blood gas values will  be lower.  We call them "Blue Bloaters". (Look at their color. It will be dusky, perhaps gray. They are worn out and just can't maintain adequate ventilation).

Scenario :Lets take another look at  Adam  carrying the O2 tank in the grocery store. Lets assume he does have emphysema.  He probably lives with an O2 saturation of 88- 90. (with the help of O2)  His PO2 is less than 80. He probably never reaches a normal  02 level.  However, he has learned to live with these low values. He has adjusted to a life with less O2 and more CO2 on board. He isn't out shoveling snow and he couldn't walk around the Mall of America... but with help he can manage to survive in a sedentary state.

Major Point here: The goal of the RN isn't going to be to 'cure'. The damage has been done and as far as we know, it is still irreversible in this day and age. 
Our goal is to help these clients maintain their baseline ABG's.
We also try to offer support and encourage healthy living.

Ponder:
You WILL encounter many many individuals who are admitted with COPD.  They are ill and you will do your best to help them return to their baseline status. As they leave the medical setting, you hear them admit that they plan to  continue smoking. You will need to communicate professionally and non judgmentally. Take some time to  think about how you will respond to these clients?

    RN's Need to Understand the Oxyhemoglobin Curve that you see below    or Fig 25-17 in H&M

                                
                                 Heuther &McCance - permission received

Major Point An O2 sat of 90 % = a PO2 of 60        - Remember This Important Point

Look at the curve. Note that O2 Sat is on the vertical . PO2 Blood gas value is horizontal (across).
Remember that _____ is a normal O2 saturation
Follow the 90 % O2 sat across and see that it merges with a PO2 of 60.
You will feel rotten if you suddenly have a PO2 of 60. (= O2 sat of 90)
Have you ever heard a nurse read a sat of 90% and say to the client "You're fine".
Don't fall into this trap.
Remember  Adam in the grocery store, carrying the O2 tank has an O2 sat of 89 or 90 %!
Do you want to live like Adam? We can't do much for Adam. 89 or 90% is the best he can ever achieve by himself. Why is this so?

A 90 % O2 sat (= PO2 of 60) means that you are  receiving adequate but not optimal O2 saturation.
Unless there is a reason ( like pneumonia, pneumothorax, chest surgery, COPD, etc) you should be very very concerned if your client has an O2 sat of only 90 %. You should be asking yourself what is going on to make it be this low. This is the minimal amount that you can tolerate and not have a need for O2
If you love your mother.... you won't want her to have an O2 sat of 90!!!!
Check it out. Find out why your client's O2 sats are below the normal 96 % . Assess for reasons.

One more important concept about Blood Gas Values...........Hang on - this is important.
Why do we breathe? What makes it all happen?

Chemoreceptors :       Your text explains chemoreceptors so well. Don't miss it!     (Fig 25 -10)
1) Where are they located?


2) How does the SNS (sympathetic nervous system) and the PSNS affect our breathing?

Read in your book about chemoreceptors in the respiratory center. 
The 'impetus to breathe' or you might say the 'driving force' is due to 2 things:

1. Decreased O2

2. Increased CO2
 

Healthy persons take a breath if the chemoreceptors sense too much CO2 in the body or too little O2 in the body.
This means you and me!

Persons with COPD have gradually lost the impetus to breathe related to Increased CO2.
Consider how they have lived with a gradual build up  of CO2 for many years.....
They are used to hypercapnia and it no longer stimulates a breath.........
These persons take a breath because their body says " Hey, I don't have enough O2, I  had better take a breath!"

Ponder:
What will happen if you turn the O2 up too far on a person with COPD?
What level of O2 saturation do we try to get a person with COPD up to ?
Let's say you are taking care of the president of the USA ( you like this fellow!) and he does not smoke.
What level of O2 saturation  do you want him or her ( someday it might be a woman) to attain ?
Ask on the discussion board if  this is confusing to you

Real life scenario: Happens all the time.......
You are working in the ER. A person arrives very SOB. No one  knows this client.  The ambulance crew viewed the SOB and turned  the O2 up to 8 liters. The RN turns the O2  down to 5 liters to maintain an O2 sat of  92 %.The staff begins assessing. ABG's are drawn and sent to the lab. The client is lethargic and  slows down his/her breathing. You get a little history and find that this client has  longstanding COPD. Breathing becomes more shallow. ABG's show that the PCO2 is abnormally high at 49. The PO2 is low at 58. The physician looks at the ABG's and says to turn the O2 down to 1 - 2 L/min.  WHY? It might sound the opposite of what you
expect!
What has happened here? This is complex but deals with the fact that this client has COPD and no longer has the stimulus to breath because of too much CO2. The only reason that this client is breathing is because chemoreceptors sense too little O2. You have just suddenly given this client lots of O2. The chemoreceptors say: "Ah this is cool! I've got all the O2 I need. No reason for me to initiate  many breaths! I haven't had it this good for a looooong time!" 
The important questions here are:
1) Why do you turn down the O2? Will this perhaps cause the client to breath more deeply?
2) What will happen to the PO2 level when you turn down the O2 level?
If you know an ER  nurse or physician, discuss this with him or her.
Be very aware that high concentrations of O2 can suppress the oxygen chemoreceptors which provide the main stimulus for breathing in clients with COPD. Often we don't see them stop breathing all together, but we see a decrease in the effort their brain makes in sending the stimulus to breathe.
If you are confused, post your questions and ask for help. This is a very difficult but important concept for RN's to understand.

 

bullet6) Eating Can be difficult --> reduced weight
Why do you suppose this might happen?
 
bullet7) Barrel Chested Configuration
Go look at your chest dimensions in a mirror.
Normally, people are twice as wide as they are deep.
In extensive COPD, the lungs become hyperinflated  from chronic air trapping.
The chest becomes round like a barrel! It is just as wide as it is deep!
What has happened to recoil after emphysema begins? ________________
Why would this contribute to hyperinflation? __________________________

Want More Information? MedLine Plus: COPD

Click on hyperlink and under search, type 'COPD' for further information

General Ideas for Treatment for chronic Bronchitis and Emphysema:
Think of some ways that you might treat these clients.
(Add to this list as you progress through the module)

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Late Stages of  COPD        Chapter 26 in H&M

1. Pulmonary Hypertension
    This means the elevation of arterial blood pressure in the pulmonary arteries.
    Is this a primary or a secondary condition  if it occurs along with COPD? ______________
    How rapidly does it progress? _________________________________
    How is it similar to right sided heart failure? Why? __________________
    What is the survival rate? _____________________________________

2. Cor Pulmonale
    Look at the words : 'cor' refers to heart. 'Pulmonale' refers to lungs.
    It is the heart and lungs failing  together.
    This occurs secondary to what?__________________________

3. Recurrent Respiratory Infections
    Why do you suppose these occur?

4. Chronic Respiratory Failure
    Do you know anyone in the "50/50 club"?
    This means they are in a state of respiratory failure
     1) Hypercapnia (increased CO2 in the blood  > 50 mg Hg)
     2) Hypoxemia (lack of adequate O2 in the blood < 50 mg Hg O2)
     The tissues are  not receiving the O2 they need for survival.
     This  eventually leads to death.
     If a healthy person suddenly becomes ill and  has blood gases that indicate   respiratory failure, what piece of
     equipment   will be needed in order to sustain life?__________________
     What might be the personal decision of a person who has longstanding COPD  regarding a ventilator?
     Has anyone in the class worked at Bethesda hospital with the long term  vent clients? Have you any insights for us?
     (Please share via the discussion board.)
     
It is very hard to wean a  COPD client off of a ventilator. Can you reason why this would be? 
     Talk to an RN at Bethesda or in an ICCU about this situation.
 

A rule of thumb for me: If the client is in the 50/50 club, he/she is in respiratory  failure and  I had better be very aware of the options for this  client- Quickly!.

Now take a look at  Figure 26-10 in H&M. Can you understand this now? If not  ask for help.               

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Pharmacology Moment: Selected Respiratory Drugs                

Several drugs are used frequently and effectively to relieve respiratory distress.
This is a great time to stop and study the respiratory pharmacology module.
It is located on the content page.


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               Pneumonia

Definition: An acute infection of the parenchymal structures of the lung.
(parenchymal = the essential or functional elements of an organ)
Thus, in the lung, this would mean the lower respiratory track : the  alveoli, alveoli duct and bronchioles,
where the gases are actually exchanged.

Etiology:
1 - 4 million cases annually in the USA
is a leading cause of death in the USA
Usually caused by infectious agents like bacteria and viruses.
May also be noninfectious - aspirate your tube feeding, inhale fumes, reflux of gastric juices from stomach -->lungs.
Ponder... How can RN's help to prevent pneumonia?

Remember, the lung should be sterile  below the larynx.
Students ask... what about all the germs that we inhale.... don't they interfere with the sterility of the lungs....good question!
Go back to your A & P.
What are the natural defenses that strive to keep the lung sterile?
 

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When these defenses fail, infections like pneumonia can occur  down in the lungs.
Pathogens multiply, stimulate the full inflammatory response, the acini fill with mucous and debris,---> serious interruptions in diffusion across the alveolar capillary membrane.
Ponder... What will the RN be assessing for? What might you expect to see?

Susceptibility to pneumonia INC with:
1) Loss of cough reflex. Picture an elderly, weakened client, lying in bed with an NG in  place, and no ability to cough effectively. How about a seriously ill client with an ET  (endotracheal) tube? Please be very aware that any time a tube is placed into the  lungs or stomach, there is an increased chance for aspiration of materials.

2) Damage to the ciliated endothelium that lines the respiratory track.
   This important filter for pathogens is damaged by cigarette smoke.
   This is just one of many reasons why a person who smokes can more easily become   ill.

3) Decreased resistance to infection: This would include:

bullet

    The young and the very old

bullet

    Persons with decreased immunity for a variety of reasons.   

bullet

    Persons with heart and lung problems


Pathophysiology: What is happening?

Involves the alveoli, alveolar ducts and interstitial spaces around the alveoli.
What does interstitial mean?
An organism enters --> causes an inflammatory process-->signs of inflammation.
What would the inside of the lungs look like if inflammation occurred? ( what are the 5 signs?)
The inflammatory process  produces an exudate (or secretion/mucous) --> edema of the tissue.
What a great medium for organisms to multiply and spread to adjacent portions of the lung!

Classifications:       Done in many different ways:

Lobar  verses Broncho
1. Lobar Pneumonia - starts in ONE area and may fill (consolidate) an entire lobe.
If a lung is consolidated, it usually means it is filled (solid) with fluid/mucous/exudate.
Can any diffusion occur here?          What happens to the client?

2. Bronchopneumonia - most common.
Inflammation starts simultaneously in several areas, producing patchy, diffuse areas of consolidation.

          

Lobar Pneumonia            Bronchial Pneumonia
www.lung.ca/pneumonia

Bacterial verses Viral (this method not widely used any more)
1. Pneumococcal /Bacterial (same as streptococcal) causes about 90 % of Pneumococcal disease.
2. Viral is less severe. Usually self limiting. No drug treatment available.

Community Acquired verses Hospital Acquired
1. Community Acquired: The organisms are found in the community rather than a  hospital.   
    Usually found in an immunocompromised person  
    Frequently associated with an upper respiratory infection (URI).
    Lower mortality rate than hospital acquired --> < 5% mortality
    Most common is pneumococcal pneumonia (= streptococcal).
    This is the type that the pneumococcal pneumonia vaccine protects against.
    Who should get this vaccine?
    How often do you need the vaccine?
    Is it dangerous?
    Need more information? Click Here. Pneumonia
                                                                   Pneumonia Vaccine

2. Hospital Acquired:
    Usually a nosocomial infection. What does nosocomial mean?
    You will hear and use this word often in your work.
    This type usually occurs  72 hours or more after admission. Why?
    Is the 2nd most common cause of hospital acquired infections.
    (What is the Most common cause of hospital acquired infection?)
    Mortality is high - 50 - 70 %
    Most caused by bacteria but of a different type.
    Ex = klebsiella, E coli and pseudomonas ( no need to memorize)

Scenario:
You are working in an urgent care setting. A 42 year old woman arrives in a lethargic condition. She tells you she "just feels rotten".  She has 4 children, works full time, admits to a lack of sleep, poor eating habits, and a general feeling of being overwhelmed with her life responsibilities. After lab and x ray are completed, she is diagnosed with pneumococcal pneumonia. What might you expect to see during your assessment?
Might she present with?

bulletFever? How high?
bulletMalaise? What does this mean?
bulletChills? When?
bulletDyspnea and Tachypnea? Why?
bulletCough? Will it be productive?
bulletWhat will the breath sounds be?
bulletWill there be chest pain?
bulletWhat else have you heard about pneumonia?

As you seek these answers, look in your book, ask health professionals and  ask your clients and friends who have had  pneumonia. Be curious.
Don't assume that symptoms are always the same with each client with pneumonia.

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Pneumocystis  Pneumonia 

A new name for this is Pneumocystis Jaroveci.
You may still see it referred to as Pneumocystis Carinii Pneumonia (PCP).
Atypical type of pneumonia. Found in persons with impaired immune systems.
Thought to be caused  probably by a fungus or maybe a parasite. (Texts differ - Remains a mystery!)
Most Americans develop antibodies to PCP in early childhood. It is actually a very common organism.
A healthy immune system controls PCP. Our immune systems prevent us from developing this disease.
However,   PCP can become active in in persons with impaired immune systems.
Major initial sx are SOB,  fever, fatigue and dry cough.
Sometimes treated prophylactically with meds such as septra and pentamidine, although this is not always the case since the advent of  better antiviral therapy.
Prophylactic treatment would start when the  person has  a T cell count < 200. Why is the 200 count significant?
What type of client's have T cell counts < 200?
Whereas this used to be a major cause of death in AIDS, it is now very preventable with good antiviral therapy and appropriate treatment with meds.

Want more information    Pneumocystis  Pneumonia
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End of the Respiratory Module.

1) Complete the Respiratory Case study and submit to your instructor.
2) Complete the Self Evaluation as many times as needed.
3) Contribute to your discussion group as per the schedule.

All through your nursing career, you will discover that RN's are frequently involved in assessment of respiratory problems. Critical thinking, competent teaching of clients  and a good plan of action can save lives and improve the quality of life for your clients, friends and family. As you put the knowledge gained in this module to work in the clinical setting, you will realize how YOU can make a difference.
Go out and be the Best you can BE!


   
 
Great Achievement !
This was a loooong module and you have just won first place for persistence!
You deserve to take some time to do something holistic for yourself! 

06/22/2009