RESPIRATORY DISORDERS

Pneumothorax
 Pneumothorax
• Pneumothorax, or a collapsed lung, is the
collection of air in the spaces around the
lungs. The air buildup puts pressure on the
lung(s), so it cannot expand as much as it
normally.
• Pneumothorax occurs when the parietal or
visceral pleura is breached and the pleural
space is exposed to positive atmospheric
pressure, the pressure in the pleural space is
normally negative.
 Classification
• Types of pneumothorax include simple,
traumatic, and tension pneumothorax
• Simple pneumothorax (Spontanious): A
simple or spontaneous pneumothorax occurs
when air enters the pleural space through
a breach of either the parietal or visceral
pleura .
• Its suddenly pneumothorax with out any
recently trauma whether primary or
secondary spontaneous.
 Classification
• Traumatic pneumothorax: A traumatic
pneumothorax occurs when air escapes from
a laceration in the lung itself and enters the
pleural space or from a wound in the chest
wall.
• Tension pneumothorax : A tension
pneumothorax occurs when air is drawn into
the pleural space from a lacerated lung or
through a small opening or wound in the
chest wall.
 Pathophysiology
• The pathophysiology of pneumothorax
include:
• Negative pressure: The negative pressure is
required to maintain lung inflation.
• Breach : When either pleura is breached, air
enters the pleural space.
• Collapse: When positive pressure has
entered the pleural space, the lung or a
portion of it collapses.
 CAUSES
• Blunt trauma: Blunt trauma like rib fractures
could cause traumatic pneumothorax.
• Invasive procedures: Traumatic
pneumothorax may occur during invasive
thoracic procedures in which the pleura is
inadvertently punctured.
• Penetrating chest or abdominal
trauma: Trauma such as stab wounds or
gunshot wounds could cause traumatic
pneumothorax.
 Clinical Manifestations
The signs and symptoms associated with
pneumothorax depend on its size and cause.
• Pain:Pain is usually sudden.
• Minimal respiratory distress: The patient
may have only minimal respiratory distress
with slight chest discomfort and tachypnea.
• Dyspnea: Due to pain, the patient has
difficulty in breathing.
• cyanosis :The patient may develop central
cyanosis from severe hypoxemia
• Chest expansion: In simple and tension
pneumothorax, chest expansion is decreased.
• Breath sounds: Breath sounds are
diminished or absent in both simple and
tension pneumothorax.
• Tracheal alignment: In simple
pneumothorax, the trachea is midline while
in tension pneumothorax, the trachea is
shifted away from the affected side.
 Assessment and Diagnosis

• Pneumothorax is assessed and diagnosed

with the following:
• Thoracic CT.
• Chest x-ray
• ABGs
• Thoracentesis
• Hb: Maybe decreased, indicating blood loss.
 Medical Management
• Medical management of pneumo thorax
depends on its cause and severity
1. Chest tube
2. Maintain a closed chest drainage system
3. Antibiotics
4. Oxygen therapy
5. Monitor a chest tube unit for any bubbling
 Surgical Management
• If more than 1500 ml of blood is aspirated
initially by thoracentesis, the rule is to open
the chest wall surgically.
• Thoracotomy: The chest wall is opened
surgically to remove the blood or air trapped
in the pleural space.
 Nursing Management

• Nursing management of a patient with

pneumothorax includes the following step
The Nurse Should Assess The Following:
• Tracheal alignment.
• Expansion of the chest.
• Breath sounds.
• Percussion of the chest
Pulmonary Edema
 Pulmonary Edema
• Definition: Pulmonary edema is a condition
characterized by fluid accumulation in the
lungs caused by back pressure in the lung
veins. This results from malfunctioning of the
heart.
• Causes: Pulmonary edema is a complication
of a myocardial infarction (heart attack),
mitral or aortic valve disease,
cardiomyopathy, or other disorders
characterized by cardiac dysfunction.
 Pathophysiology
• Fluid backs up into the veins of the lungs.
Increased pressure in these veins forces fluid
out of the vein and into the air spaces
(alveoli). This interferes with the exchange of
oxygen and carbon dioxide in the alveoli
 Clinical Manifestations
• Extreme shortness of breath "airhunger“
• Sounds with breathing Inability to lie down
Wheezing Anxiety.
• Restlessness
• Cough
• Excessive
• sweating
• Pale skin
• Coughing up blood Breathing
• Absent temporarily.
 Clinical Manifestations
• Listening to the chest with a stethoscope
(auscultation) may show crackles in the
lungs or abnormal heart sounds.
• A chest x-ray may show fluid in the lung
space.
• An echocardiogram may be performed in
addition to (or instead of) a chest x-ray.
 Tests
• Blood oxygen levels (low)
• An ultrasound of the heart
 Treatment
• This is a medical emergency! Do not delay
treatment.
• Hospitalization and immediate treatment
are required.
• Oxygen is given, by a mask or through
 Treatment
• Medications include diuretics such as
furosemide to remove fluid, vasodilators to
help the heart pump better, drugs to treat
anxiety, and other medications to treat the
underlying cardiac disorder.
 Expectations (Prognosis)
• Pulmonary edema is a life-threatening
condition. It is often curable with urgent
treatment and subsequent control of the
underlying disorder.
 Complications
• Long-term dependence on a breathing
machine (ventilator).
• Patient Education: In patients with known
diseases that can lead to pulmonary edema,
strict compliance with taking medications in a
timely manner and following an appropriate
diet (usually, low in salt) can significantly
decrease one's risk.
Bronchiectasis
 Bronchiectasis
• Chronic pulmonary disorders are the leading
cause of morbidity and mortality in the whole
world.
• Bronchiectasis is a chronic, irreversible
dilation of the bronchi and the bronchioles.
 Pathophysiology
• Bronchiectasis is usually localized, affecting a
segment or lobe of a lung, most frequently
the lower lobes.
• Inflammation: The inflammatory process
associated with
pulmonary infection damages the bronchial
wall, causing a loss of its supporting
structure and resulting in thick sputum that
ultimately obstructs the bronchi.
• Distention: The walls become permanently
distended and distorted.
 Pathophysiology
• Collapse. The retention of secretions and
subsequent obstruction ultimately cause the
alveoli distal to the obstruction collapse.
• Scarring. Inflammatory scarring or fibrosis
replaces functioning lung tissue.
• Impairment. There is impairment in the match
of ventilation to perfusion and hypoxemia.
 Causes
• Bronchiectasis may be caused by a variety of conditions
including:
1. Airway obstruction: Obstructions in the bronchi
distend the wall permanently.
2. Pulmonary infection : Pulmonary infection and
obstruction of the bronchus or complications of long-
term pulmonary infections cause bronchiectasis.
3. Genetic disorders : Genetic disorders such as
cystic fibrosis causes the sputum to thicken in
consistency and would ultimately obstruct the
bronchi.
4. Idiopathic causes : There are causes that are
unknown to medicine that cause bronchiectasis
 Clinical Manifestations
Characteristic symptoms of bronchiectasis include:
• Chronic cough: Cough that has been going on for two
months or more may be indicative of bronchiectasis.
• Purulent sputum : Production of purulent sputum.
• Hemoptysis : Many patients with this disease have
hemoptysis.
• Clubbing of the fingers : Clubbing of the fingers is
also a common symptom because of respiratory
insufficiency.
• Recurrent infection : Patients have repeated episodes
of pulmonary infection.
 Complications
• Potential complications include:
• Atelectasis: Collapse of the alveoli is a
common complication.
• Pneumonia: Infection is recurrent in patients
with bronchiectasis.
• Empyema: Over production of sputum
causes the bronchi to be filled with pus.
 Assessment and Diagnostic
Findings
• Bronchiectasis is not readily diagnosed
because symptoms can be mistaken for those
of a simple chronic bronchitis.
• History of productive cough: A definite sign
is a prolonged history of productive cough,
with sputum negative for tubercle bacilli.
• CT scan: The diagnosis is established by a CT
scan, which reveals bronchial dilation.
 Medical Management
• Treatment objectives are to promote bronchial
drainage to clear excessive secretions from the
affected portion of the lungs and to prevent or
control infection.
• Postural drainage: Postural drainage is part of
all treatment plans, because draining of the
bronchiectatic areas by gravity reduces the
amount of secretions and the degree of infection.
• Chest physiotherapy: Chest physiotherapy,
including percussion and postural drainage, is
important in the management of secretions.
 Pharmacologic Therapy
• Antimicrobial therapy: Antimicrobial
therapy based on the results of sensitivity
studies on organism cultured from sputum is
used to control infection.
• Bronchodilators: Bronchodilators, which
may be prescribed for patients who have
reactive airway disease, may also assist with
secretion management.
 Surgical Management
• Surgical intervention may be indicates for
patients who continue to expectorate large
amounts of sputum and have repeated bouts
of pneumonia.
 Nursing Assessment
• Nursing assessment of a patient with
bronchiectasis include:
• Evaluation of current smoking status.
• Evaluation of current exposure to
occupational toxins or pollutants and in
indoor/outdoor pollution.
• Assess the patient’s current level of
functioning.
PULMONARY EMPLISM
 Pulmonary Embolism
• Pulmonary embolism refers to
the obstruction of the pulmonary artery or
one of its branches by a thrombus that
originates somewhere in the venous system
or in the right side of the heart.
• Deep vein thrombosis: a related condition,
refers to thrombus formation in the deep
veins, usually in the calf or thigh, but
sometimes in the arm, especially in patients
with peripherally inserted central catheters.
 Classification
• Most commonly, pulmonary embolism is due
to a blood clot or thrombus, but there are
other types of emboli: fat, air, amniotic fluid
and septic.
1. Fat emboli. Fat emboli are cholesterol or
fatty substances that may clog the arteries
when fatty foods are consumed more.
2. Air emboli. Air emboli usually come from
intravenous devices.
3. Septic emboli. Septic emboli originate from
a bacterial invasion of the thrombus.
 Pathophysiology
• A series of happenings occur inside a patient’s
body when he or she has emboli.
• Obstruction When a thrombus completely or
partially obstructs the pulmonary artery or its
branches, the alveolar dead space is increased.
• Impairment. The area receives little to no blood
flow and gas exchange is impaired.
• Constriction. Various substances are released
from the clot and surrounding area that cause
constriction of the blood vessels and results in
pulmonary resistance.
• Consequences. Increased pulmonary
vascular resistance due to regional
vasoconstriction leading to increase in
pulmonary arterial pressure and increased
right ventricle workload are the
consequences that follow.
• Failure. When the workload of the right
ventricle exceeds the limit, failure may occur.
 EPIDEMIOLOGY
• Pulmonary embolism may be the primary
cause or a major contributory cause in as
many as 200,000 deaths per year in the US.
Most of these deaths occur in patients in
whom the diagnosis is not suspected and,
thus, not treated.
• The mortality rate for untreated pulmonary
embolism is approximately 30%.
 Causes
Pulmonary embolism is linked to a lot of causes and
these are the most common:
1. Trauma: Trauma anywhere in the body could cause
PE especially if a clot is released from the venous
system.
2. Surgery: Certain surgical procedures such as
orthopedic, major abdominal, pelvic, and
gynecologic surgeries could cause PE.
3. Hypercoagulable states: A patient with
hypercoagulability disorders would most likely
develop a clot that could result in PE.
4. Prolonged immobility: Being unable to move for a
prolonged time predisposes a person to PE.
 Clinical Manifestations
Symptoms of a pulmonary embolism depend on the
size of the thrombus and the area of the
pulmonary artery occluded by the thrombus.
1. Dyspnea: Dyspnea is the most frequent
symptom; the duration and intensity of the
dyspnea depend on the extent of embolization.
2. Chest pain: Chest pain occurs suddenly and is
pleuritic in origin.
3. Tachycardia: Increase in heart rate occurs
because the right ventricle catches up with its
workload.
4. Tachypnea :The most frequent sign is tachypnea
 Prevention
For patients at risk for PE, the most effective approach for prevention
is to prevent DVT.
1. Avoid venous stasis: Active leg exercises, early ambulation, and
use of anti-embolism stockings are general preventive measures
for DVT.
2. Sequential compression devices: These are plastic sleeves that
can be inflated with air for compression and relaxation of calf
muscles.
3. Mechanical prophylaxis: Mechanical prophylaxis can be
classified as static or dynamic.
4. Graduated compression stockings: This involves the sequential
movement of air in the sleeve up the leg, followed by relaxation
of the sleeve.
5. Anticoagulant therapy: Anticoagulant therapy may be
prescribed for patients whose hemostasis is adequate and who
are undergoing major elective abdominal or thoracic surgery.
 Complications

• When caring for a patient who has had PE,

the nurse must be alert for potential
complications.
1. Cardiogenic shock: The cardiopulmonary
system is endangered in a massive PE.
2. Right ventricular failure: A sudden increase
in pulmonary resistance increases the work
of the right ventricle.
 Assessment and Diagnostic Findings

• Death from PE commonly occurs within one (1) hour

after the onset of symptoms; therefore, early recognition
and diagnosis are priorities.
1. Chest x-ray: The chest x-ray is usually normal but may
show infiltrates, atelectasis, the elevation of
the diaphragm on the affected side, or pleural effusion.
2. ECG: The ECG usually shows sinus tachycardia, PR-
interval depression, and nonspecific T-wave changes.
3. ABG: analysis: ABG analysis may
show hypoxemia and hypocapnia; however, ABG
measurements may be normal even in the presence of
PE.
4. Pulmonary angiogram: Pulmonary angiogram allows
for direct visualization under fluoroscop
 Medical Management
• Because PE is often a medical emergency,
emergency management is of primary concern.
1. Anticoagulation therapy: Heparin,
and warfarin has been traditionally been the
primary method for managing acute DVT and
PE.
2. Thrombolytic therapy: Urokinase,
streptokinase, alteplase are used in treating
PE, particularly in patients who are severely
compromised.
 Surgical Management
• Removal of the emboli may sometimes need surgical
management.
1. Surgical embolectomy: This is the removal of the
actual clot and must be performed by a
cardiovascular surgical team with the patient on
cardiopulmonary bypass.
2. Transvenous catheter embolectomy: This is a
technique in which a vacuum-cupped catheter is
introduced transvenously into the affected
pulmonary artery.
3. Interrupting the vena cava: This approach prevents
dislodged thrombi from being swept into the lungs
while allowing adequate blood flow.
 Nursing Assessment
• All patients are evaluated for risk factors for
thrombus formation and pulmonary embolus.
1. Health history: Health history is assessed to
determine any previous cardiovascular disease.
2. Family history: History of any cardiovascular
disease in the family may predispose the patient
to PE.
3. Medication record: There are certain
medications that can increase the risk for PE.
4. Physical exam: Extremities are evaluated for
warmth, redness, and inflammation.
 ASSIGMENT NURSING CARE PLAN

• Based on the assessment data,

developed Nursing Care plan for a patient
with pulmonary embolism:
1. Diagnosis (ONE)
2. Planning & Goals ( at least three)
3. INTERVENTIONS ( at least three)
4. Evaluation ( at least three)
END