Respi Patho 1

RESPIRATORY SYSTEM DISORDERS

RHINITIS • is a group of disorders characterized by inflammation and irritation of the mucous membranes of the nose. • It may be classified as nonallergic or allergic. • It is estimated that 10% to 15% of the population of the United States has allergic rhinitis • Rhinitis may be an acute or chronic condition.

Pathophysiology • Nonallergic rhinitis – may be caused by a variety of factors including • environmental factors – – – –

Changes in temperature or humidity Odors Foods Infection

• age • systemic disease • Drugs (cocaine) or prescribed medications

• Drug-induced rhinitis is associated with use of antihypertensive

• agents and oral contraceptives and chronic use of nasal decongestants.

• Rhinitis – also may be a manifestation of an allergy – referred to as allergic rhinitis and sinusitis.

Clinical Manifestations • rhinorrhea (excessive nasal drainage, runny nose) • nasal congestion • nasal discharge (purulent with bacterial rhinitis) • nasal itchiness • sneezing. • Headache may occur, particularly if sinusitis is also present.

Medical Management • depends on the cause • Viral rhinitis is the cause - medications are given to relieve the symptoms. • Allergic rhinitis - to identify possible allergens. • Desensitizing immunizations and corticosteroids may be required • Bacterial infection - antimicrobial agent

PHARMACOLOGIC THERAPY • Medication therapy for allergic and nonallergic rhinitis focuses on symptom relief. • Antihistamines: sneezing, itching, and rhinorrhea. • Oral decongestant agents : nasal obstruction. • Intranasal corticosteroids : severe congestion • Ophthalmic agents : relieve irritation, itching, and redness of the eyes.

VIRAL RHINITIS (COMMON COLD) • The term “common cold”: used when referring to an upper respiratory tract infection that is self-limited and caused by a virus (viral rhinitis). • Nasal congestion, rhinorrhea, sneezing, sore throat, and general malaise • Specifically, the term “cold” refers to an afebrile, infectious, acute inflammation

VIRAL RHINITIS (COMMON COLD) • highly contagious • virus is shed for about 2 days before the symptoms appear and during the first part of the symptomatic phase. • average two to four colds each year. • the most common cause of absenteeism from work and school

• The six viruses known to produce the signs and symptoms of the viral rhinitis are – – – – – –

Rhinovirus parainfluenza virus Coronavirus respiratory syncytial virus (RSV) influenza virus adenovirus

Clinical Manifestations • • • • • • •

nasal congestion Runny nose Sneezing nasal discharge nasal itchiness tearing watery eyes “scratchy” or sore throat

• • • • •

general malais low-grade fever Chills headache muscle aches.

Medical Management • no specific treatment for the common cold or influenza. • Symptomatic therapy. • Some measures include – providing adequate fluid intake – encouraging rest – increasing intake of vitamin C – using expectorants as needed. – Warm salt-water gargles soothe the sore throat – nonsteroidal anti-inflammatory agents (NSAIDs) such as aspirin or ibuprofen relieve the aches, pains, and fever in adults. – Antihistamines are used to relieve sneezing, rhinorrhea, – Nasal congestion. Topical (nasal) decongestant agents

ACUTE SINUSITIS • Sinuses – mucus-lined cavities filled with air that drain normally into the nose – are involved in a high proportion of upper respiratory tract infections. – If their openings into the nasal passages are clear, the infections resolve promptly.

• drainage is obstructed by a deviated septum or by hypertrophied turbinates, spurs, or nasal polyps or tumors, sinus infection may persist as a smoldering secondary infection or progress to an acute suppurative process (causing purulent discharge).

Pathophysiology • Acute sinusitis – is an infection of the paranasal sinuses.

• Frequently develops as a result of an upper respiratory infection, such as an – unresolved viral or bacterial infection – an exacerbation of allergic rhinitis. – Nasal congestion, caused by inflammation, edema, and transudation of fluid, leads to obstruction of the sinus cavities

• This provides an excellent medium for bacterial growth.

• occupations. – hazards such as paint, sawdust, and chemicals

• Bacterial organisms account for more than 60% of the cases of acute sinusitis, namely – Streptococcus pneumoniae – Haemophilus influenzae, and Moraxella catarrhalis – Dental infections also have been associated with acute sinusitis.

Clinical Manifestations • • • • • • • • • • • •

facial pain or pressure over the affected sinus area nasal obstruction fatigue purulent nasal discharge Fever Headache ear pain and fullness Dental pain Cough a decreased sense of smell sore throat eyelid edema or facial congestion or fullness.

Assessment and Diagnostic Findings • careful history and physical examination are performed. – The head and neck, particularly the nose, ears, teeth, sinuses, pharynx, and chest, are examined. - tenderness to palpation over the infected sinus area. - The affected area is also transilluminated; with sinusitis,

Assessment and Diagnostic Findings • Sinus x-rays may be performed to detect sinus opacity, mucosal thickening, bone destruction, and air–fluid levels. • Computed tomography scanning of the sinuses is the most effective diagnostic tool. – It is also used to rule out other local or systemic disorders, such as tumor, fistula, and allergy

CHRONIC SINUSITIS • is an inflammation of the sinuses that persists for more than 3 weeks in an adult and 2 weeks in a child.

Pathophysiology • A narrowing or obstruction in the ostia of the frontal, maxillary, and anterior ethmoid sinuses usually causes chronic sinusitis, preventing adequate drainage to the nasal passages.

Pathophysiology • Blockage that persists for greater than 3 weeks in an adult may occur because of infection allergy, or structural abnormalities. • This results in stagnant secretions, an ideal medium for infection.

Pathophysiology • organisms that cause chronic sinusitis are the same as those implicated in acute sinusitis • Immunocompromised patients, – risk for developing fungal sinusitis. – Aspergillus fumigatus • most common

Clinical Manifestations • impaired mucociliary clearance and ventilation • cough (because the thick discharge constantly drips backward into the nasopharynx) • Chronic hoarseness • Chronic headaches in the periorbital area, and facial pain.

• symptoms are generally most pronounced on awakening in the morning. • Fatigue and nasal stuffiness are also common. • decrease in smell and taste and a fullness in the ears.

Assessment and Diagnostic Findings • history and diagnostic assessment • Computed tomography scan • magnetic resonance imaging (if fungal sinusitis is suspected), are performed to rule out other local or systemic disorders, such as tumor, fistula, and allergy. • Nasal endoscopy

Complications • • • • • •

severe orbital cellulitis subperiosteal abscess cavernous sinus thrombosis Meningitis Encephalitis ischemic infarction.

Medical Management • The antimicrobial agents of choice include – amoxicillin clavulanate (Augmentin) or ampicillin (Ampicin). – Clarithromycin (Biaxin) and third-generation cephalosporins such as cefuroxime axetil (Ceftin), cefpodoxime (Vantin), and cefprozil (Cefzil) have also been effective – . Levofloxacin (Levaquin) a quinolone – 3 to 4 weeks. – Decongestant agents, antihistamines, saline sprays, and heated mist

SURGICAL MANAGEMENT • Excising and cauterizing nasal polyps, correcting a deviated septum • Incising and draining the sinuses • aerating the sinuses, and removing tumors

Nursing Management • promote sinus drainage by – increasing the environmental humidity (steam bath, hot shower, and facial sauna) – increasing fluid intake, and applying local heat (hot wet packs).

• follow the medication regimen. • Instructions on the early signs of a sinus infection are provided and preventive measures are reviewed.

ACUTE PHARYNGITIS

• inflammation or infection in the throat, usually causing symptoms of a sore throat.

Pathophysiology • viral infection • group A beta-hemolytic streptococcus – the most common bacterial organism, – causes acute pharyngitis, the condition is known as strep throat

• The body responds by triggering an inflammatory response in the pharynx. • pain, fever, vasodilation, edema, and tissue damage, manifested by redness and swelling in the tonsillar pillars, uvula, and soft palate. • creamy exudate may be present in the tonsillar pillars

• Uncomplicated viral infections – subside promptly – within 3 to 10

• group A beta-hemolytic streptococci – is a more severe illness. – left untreated, the complications can be severe and life-threatening.

• Group A beta-hemolytic streptococci – Complications include • • • • •

Sinusitis otitis media peritonsillar abscess Mastoiditis cervical adenitis

• In rare cases may lead to – Bacteremia – Pneumonia – Meningitis – rheumatic fever – nephritis

Clinical Manifestations • fiery-red pharyngeal membrane and tonsils • Swollen lymphoid follicles flecked with whitepurple exudate • enlarged and tender cervical lymph nodes • Fever • Malaise • sore throat

Assessment and Diagnostic Findings • Rapid screening tests for streptococcal antigens such as – – – – –

the latex agglutination (LA) antigen test solid-phase enzyme immunoassays (ELISA) optical immunoassay (OIA) streptolysin titers throat cultures

• Nasal swabs and blood cultures

Medical Management • Viral : supportive measures • Bacterial pharyngitis: antimicrobial agents.

PHARMACOLOGIC THERAPY • bacterial : penicillin is usually the treatment of choice. • Allergies to penicillin and resistance : cephalosporins and macrolides (clarithromycin and azithromycin) • 10 days • Severe sore throats : analgesic medications

NUTRITIONAL THERAPY • A liquid or soft diet • severe situations: IV fluids • 2 to 3 L per day of fluids

CHRONIC PHARYNGITIS • persistent inflammation of the pharynx. • It is common in adults who work or live in dusty surroundings, use their voice to excess, suffer from chronic cough, and habitually use alcohol and tobacco

• Three types of chronic pharyngitis are recognized: – Hypertrophic: • 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”): • numerous swollen lymph follicles on the pharyngealwall

Clinical Manifestations • constant sense of irritation or fullness in the throat • mucus that collects in the throat – can be expelled by coughing

• difficulty swallowing.

Medical Management • Treatment of chronic pharyngitis is based – on relieving symptoms – avoiding exposure to irritants – correcting any upper respiratory, pulmonary, or cardiac condition that might be responsible for a chronic cough.

• Nasal congestion – Nasal sprays or medications containing ephedrine sulfate (Kondon’s Nasal) or phenylephrine hydrochloride (Neo-Synephrine).

• Antihistamine decongestant medications – Drixoral or Dimetapp, is taken orally every 4 to 6 hours.

• Aspirin or acetaminophen – antiinflammatory and analgesic properties.

TONSILLITIS AND ADENOIDITIS • Tonsils – each side of the oropharynx. – faucial or palatine tonsils and lingual tonsils • located behind the pillars of fauces and tongue,

– serve as the site of acute infection (tonsillitis).

• Chronic tonsillitis is less common

• Infection nof the adenoids frequently accompanies acute tonsillitis. • Group A beta-streptococcus – the most common organism associated with tonsillitis and adenoiditis.

Clinical Manifestations • sore throat, fever, snoring, • and difficulty swallowing. • Enlarged adenoids may cause mouthbreathing, • earache, draining ears, frequent head colds, bronchitis, • foul-smelling breath, voice impairment, and noisy respiration.

Tonsillitis & Adenoiditis - Dx Dx • Visualize • C&S

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Mono

Medical Management • Tonsillectomy – medical treatment is unsuccessful – there is severe hypertrophy, asymmetry, or peritonsillar abscess that occludes the pharynx – swallowing difficult – endangering the airway (particularly during sleep).

Indications • repeated bouts of tonsillitis • hypertrophy of the tonsils and adenoids that could cause obstruction and obstructive sleep apnea; • repeated attacks of purulent otitis media • suspected hearing loss due to serous otitis media • exacerbation of asthma or rheumatic fever.

Tonsillitis & Adenoiditis - Tx • Kissing tonsil's

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THIS IS NOT TONSILLITIS! In this picture taken a week after tonsillectomy, the tonsils have been removed and the whitish discoloration in the tonsillectomy bed is the eschar that forms postoperatively.

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This is normal after a tonsillectomy and should not be confused with infection.

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Occasionally, this white eschar falls off prematurely, causing delayed postoperative hemorrhage

Tonsillitis & Adenoiditis Post-op care • Hemorrhaging – Coffee ground emeses – Bright red emeses – Pulse  

– Temp 

– Restlessness – Tarry stool   swallowing

Tonsillitis & Adenoiditis Post-op • Position – Prone/side lying until… • Gag returns

– Semi-fowler’s

• Pain control – Ice collar – Acetaminophen • Not aspirin

Tonsillitis & Adenoiditis Post-op • Diet – Ice cold fluids – Adv. To normal ASAP • 2-3 days

– Milk products  

– Avoid • • • •

Spicy Hot Acidic Rough

Tonsillitis & Adenoiditis • Post-op • Pt education – S&S of hemorrhaging – Mouthwash good – Avoid • • • • •

Coughing Sneezing Vigorous nose blow Vigorous gargling Rough foods

– Expect black tarry stools – Normal activity ASAP

Peritonsillar Abscess Pathophysiology • Pus & blood filled sacs on tonsil Etiology • Complication of strep throat

Peritonsillar Abscess S&S • Pain – Local – Radiates  ear

• Dysphagia – drooling

• Dysphasia • Fever • Red throat

Peritonsillar Abscess Tx • Antibiotics • Incision & drain – Lanse

• Warm saline irrigation • Hydrogen peroxide • Analgesics – – – –

Topical Tylenol No aspirin ? narcotics

• Ice collar • No smoking • Ventilator?

• most common antimicrobial agent: oral penicillinwhich is taken for 7 days. • Amoxicillin and erythromycin are alternatives.

LARYNGITIS • inflammation of the larynx, • Result of voice abuse or exposure to dust, chemicals, smoke, and other pollutants, or as part of an upper respiratory tract infection.

• Most common cause: Virus • Secondary bacterial infection • Associated with allergic rhinitis or pharyngitis • Associated with exposure to sudden temperature changes, dietary deficiencies, malnutrition, and an immunosuppressed state.

• Laryngitis is common in the winter and is easily transmitted

Clinical Manifestations • • • •

hoarseness aphonia (complete loss of voice) severe cough. Chronic laryngitis is marked by – persistent hoarseness.

• Laryngitis may be a complication of upper respiratory infections.

Medical Management • resting the voice • avoiding smoking, resting, and inhaling cool steam or an aerosol. • appropriate antibacterial therapy

• Chronic laryngitis: treatment includes – resting the voice – eliminating any primary respiratory tract infection – Eliminating smoking – avoiding second-hand smoke.

• Topical corticosteroids – beclomethasone dipropionate (Vanceril) inhalation, may also be used. – may reduce local inflammatory reactions.

Chest and Lower Respiratory Tract Disorders

Atelectasis • Collapse or airless condition of the alveoli caused byhypoventilation,obstruction of airway or compression

Pathophysiology • reduced alveolar ventilation or any type of blockage that impedes the passage of air to and from the alveoli that normally receive air through the bronchi and network of airways. • isolated portion of the lung becomes airless and the alveoli collapse.

Causes • altered breathing patterns • Retained secretions, pain, alterations in small airway function • Prolonged supine positioning • increased abdominal pressure • reduced lung volumes due to musculoskeletal or neurologic disorders • Restrictive defects, and specific surgical procedures (eg, upper abdominal thoracic, or open heart surgery).

• Atelectasis may also result from – excessive pressure on the lung tissue, which restricts normal lung expansion on inspiration. • fluid accumulating within the pleural space (pleural effusion), • air in the pleural space (pneumothorax) • blood in the pleural space (hemothorax).

Clinical Manifestations • usually is insidious. • Signs and symptoms include – – – – – –

cough sputum production low-grade fever marked respiratory distress (lobar atelectasis) dyspnea, tachycardia, tachypnea, pleural pain, and central cyanosis

Assessment and Diagnostic Findings • Decreased breath sounds and crackles are heard over the affected area. • Chest x-ray: patchy infiltrates or consolidated areas. • pulse oximetry: (SpO2) low saturation of hemoglobin with oxygen (less than 90%) • lower-than-normal partial pressure of arterial oxygen (PaO2).

Atelectasis • Management 1. First line measures :(turning , early ambulation , lung volume expansion , coughing, spirometry ,breathing exercises 2. If there is no response : (PEEP , IPPB) 3. Bronchoscopy 4. Postural Drainage & percussion 5. If cause is compression remove the cause

positive expiratory pressure or PEP therapy

Preventing Atelectasis • Change patient’s position frequently, especially from supine to upright position, to promote ventilation and prevent secretions from accumulating. • Encourage early mobilization from bed to chair followed by early ambulation. • Encourage appropriate deep breathing and coughing to mobilize secretions and prevent them from accumulating.

Preventing Atelectasis • Teach/reinforce appropriate technique for incentive spirometry. • Administer prescribed opioids and sedatives judiciously to prevent respiratory depression. • Perform postural drainage and chest percussion, if indicated. • Institute suctioning to remove tracheobronchial secretions, if indicated.

Acute Tracheobronchitis •

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An inflammation of the mucus membrane of the trachea & the bronchial tree , often follow upper respiratory tract infection Inhalation of physical and chemical irritants, gases, and other air contaminants can also cause acute bronchial irritatation

Causes • • • •

Streptococcus pneumoniae Haemophilus influenzae Mycoplasma pneumoniae Fungal infection (eg, Aspergillus tracheobronchitis)

Clinical Manifestations 1.Dry irritating cough “expectorate sputum” 2. Sternal soreness from coughing 3. Fever ,stress , night sweating 4. Headache & general malaise 5. As the infection progress the patient develop (shortness of breath, noisy breath ,& purulent sputum

Medical Management 1. Antibiotics depend on symptoms & culture 2. Expectorant may be prescribed 3. Increase fluid intake 4. Rest & cool therapy 5. Suctioning & Bronchoscopy

Pneumonia • An inflammation of the lung tissue that is caused by microbial agent • “Pneumonitis” is a more general term that describes an inflammatory process in the lung tissue

• caused by various microorganisms, • including bacteria, mycobacteria, chlamydiae, mycoplasma, • fungi, parasites, and viruses.

• Conditions that produce mucus or bronchial obstruction and interfere with normal lung drainage (eg, cancer, cigarette smoking, COPD) • Immunosuppressed patients and those with a low neutrophil count (neutropenic) • Smoking; cigarette smoke disrupts both mucociliary and macrophage activity • Prolonged immobility and shallow breathing pattern

• pneumonia has been categorized into • one of four categories: bacterial or typical, atypical, anaerobic/ • cavitary, and opportunistic. However, there is overlap in the microorganisms • thought to be responsible for typical and atypical pneumonias.

• A more widely used classification scheme categorizes the • major pneumonias as community-acquired pneumonia, hospitalacquired • pneumonia, pneumonia in the immunocompromised • host, and aspiration pneumonia

• Community Acquired Pneumonia (CAP) 1. Occurs either in community setting or within the first 48 hrs of hospitalization 2. Most common in people younger than 60 yrs 3. Most prevalent during winter & spring 4. Caused by pneumococcus & H influenza 5. Virus the cause in infants & children

Community-Acquired Pneumonia • Streptococcus pneumoniae • winter months. • the elderly and in patients with COPD, heart failure, alcoholism, asplenia, following influenza

Hospital Acquired Pneumonia (HAP) • the onset of pneumonia symptoms more than 48 hrs after admission to hospital. • Also called nosocomial infection • Common organism E.colli ,Klebsiella ,S.aurious • It occurs when host defense impaired in certain conditions

Pneumonia in the Immuno compressed host • Caused by organisms also observed in CAP,HAP. • Has subtle onset with progressive dyspnea , fever , &productive cough

Pneumonia • Clinical Manifestations 1. Sudden onset of shaking chills 2. Rapidly increase in body temperature 38-40 C 3. Chest pluratic pain increased by deep breathing 4. Patient looks severely ill with marked tachypnea

Pneumonia 1. 2. 3. 4. 5.

Shortness of breath Orthopnea Poor appetite Diaphoresis &tires easily Purulent sputum

Pneumonia • Medical Management 1. Appropriate antibiotics depend on culture result 2. Hydration (increase fluid intake ) 3. Antipyretic for fever & Headache 4. Warm moist inhalation to relieve irritation

1. Antihistamine to relieve sneezing & rhinorrhea 2. Oxygen & respiratory supportive measures • Complications : Shock & respiratory failure , Atelectasis & plural effusion Super infection

• • • • • • •

The nurse should monitor the following: • Changes in temperature and pulse • Amount, odor, and color of secretions • Frequency and severity of cough • Degree of tachypnea or shortness of breath • Changes in physical assessment findings (primarily assessed • by inspecting and auscultating the chest) • • Changes in the chest x-ray findings