Upper respiratory disorders in adults and children

Upper respiratory disorders in adults and children Fall 2004 NVCC Amanda Brooks RN, FNP Kozier & Erb, Lemone & Burke, London The respiratory system          Purpose-oxygenate cells, rid body of carbon dioxide Inspiration is active, expiration is passive Respiratory rate is controlled by medulla oblongata and pons in the brain. Rate is controlled by amount of CO2-rate increases when CO2 increases, or pH decreases. Hemoglobin carries oxygen in the blood Lungs Right lung is larger with 3 lobes, left lung has 2 Trachea divides into right and left main bronchi Bronchi divide into bronchioles which end in alveoli-small sacs where air exchange occurs Rate Rhythm Quality Agonal Biots breathing Bradypnea Cheyne-stokes Kussmaul Tachypnea To assess breathing                 Types of respiration Physical assessment History Observation Exam-Remember: inspect, palpate, percuss, auscultate Assess chest expansion Tactile fremitus Percussion Diaphragmatic excursion auscultation     Make sure patient is breathing through an open mouth Be systematic Listen for abnormal or absent breath sounds If abnormal breath sounds are heard, then test for bronchophony, whispered pectoriloquy, egophony Acid Base imbalance        Cellular function is dependent on proper pH within the body Acidity of the blood is determined by the number of hydrogen ions present Acidosis-increased acidity in the blood due to an accumulation of acids or an excessive loss of bicarb. Alkalosis-an increase in blood alkalinity due to accumulation of bases or reduction of acids Acid base imbalances are either respiratory or metabolic Respiratory imbalance due to imbalance of carbon dioxide Metabolic imbalance due to imbalance of hydrogen ions and bicarb regulated by the kidneys Buffer system Respiratory system Renal system Regulatory systems             Bicarbonate-carbonic acid buffer system Bicarb-HCO3 A weak base added to the system when excess acid is present Carbonic acid-H2CO3 Weak acid-broken down to H2O and CO2, which is excreted by the lungs Hemoglobin and phosphates act as buffers also The respiratory system CO2 forms carbonic acid when mixed with water Carbonic acid level in the body is regulated by the respiratory center in the brain-CO2 is either eliminated or retained   Increased acid levels cause rate and depth of inspiration to increase-CO2 (and carbonic acid levels) drops Decreased acid levels cause decreased rate and depth of respirations, so CO2 and carbonic acid are retained The respiratory system works quickly to correct the problem, but can not maintain over the long term Note well-patients with chronic lung disease will have an elevated CO2 level as their baseline The renal system      The kidneys are responsible for regulation of bicarbonate (a base) in the body They react slower, but can maintain balance over time Kidneys can produce and excrete bicarbonate and either retain or excrete hydrogen ions Compensation           When one system is off, the other tries to compensate Compensation can either be partial or complete pH 7.35-7.45 normal PCO2 35-45 mmHg HCO3 22-26 PO2 80-100 Normal values How to interpret ABGs 1. look at the pH-normal, acidotic or alkalotic? Draw an arrow indicating value is either up or down 2. look at PCO2-normal, acidotic or alkalotic? Draw an arrow indicating value is either up or down 3. look at HCO3-normal, acidotic or alkalotic? Draw an arrow indicating value is either up or down CAUSES  Lactic acidosis  Diabetic ketoacidosis  Diarrhea Interpretation of acid base disorders Metabolic acidosis decreased pH, decreased HCO3 SYMPTOMS  Headache  Hyperventilation (Kussmaul’s respirations)  Hyperkalemia  Muscle twitching  Decreased LOC  Nausea/vomiting Metabolic alkalosis increased pH, increased HCO3 CAUSES  Vomiting  Gastric suctioning  Excess bicarobonate ingestion or administration SYMPTOMS  Confusion and decreased LOC  Hypotension  Dysrythmias  Respiratory failure  Diarrhea  seizures Respiratory acidosis decreased pH, increased PCO2 CAUSES  Acute respiratory conditions  Opiate overdose  Foreign body aspiration  MS  CVA SYMPTOMS  Headache  Decreased LOC and disorientation  Increased cardiac output  Increased BP-may have cardiac arrest   Hypoventilation Muscle weakness CAUSES  hyperventilation  Fever Respiratory alkalosis increased pH, decreased PCO2 SYMPOTMS  Seizures  Confusion  Tingling in extremities  Lightheadedness  Palpitations  Anxiety/panic   Abnormal PCO2 indicates a respiratory disorder Abnormal HCO3 indicates a metabolic disorder What happens next?    The body will try to correct the imbalance If the lungs are causing the imbalance-(abnormal CO2), the kidneys will try to compensate If the kidneys are causing the imbalance (abnormal HCO3), the lungs will try to compensate APNEA Periodic breathing in children is normal-defined as periodic breathing with pauses of up to 20 seconds Apnea is breathing with greater than 20 second pauses, accompanied by cyanosis, pallor, hypotonia, and bradycardia  Apparent Life threatening event (ALTE) An episode of apnea that usually requires emergency resuscitation. May occur in sleep, while awake, or during a feeding. Causes may include: functional airway problem, cardiac problem, aspiration or GERD, infection, neurological disorder, metabolic disorder      50% of the cases have no cause      Nursing management of ALTE Monitor cardiorespiratory status-pulse oximetry is non-invasive. SaO2 under 95% is hypoxemia Emotional support for parents and family Medications Be prepared for emergency Discharge planning Emotional support     Explain procedures, tests and monitoring equipment. Establish open communication. Parents often feel anxiety related to their infant’s diagnosis and prognosis. Encourage active participation of the child’s care. Advise the parents that touching the child will help the child remember to breathe Medications Methylxanthines (caffeine or aminophylline), or doxapram can be administered to stimulate respiratory center in brain. Caffeine is preferred-it is longer acting, is more stable in the blood, and it has fewer side effects. REMEMBER!!—infants have immature hepatic and renal systemsmonitor drug levels often Discharge planning Make sure parents know how to use apnea monitor, and what to do if child does stop breathing. They should notify utility companies and local rescue squad of child’s status Keep emergency contact and procedures in easily accessible places Check monitor frequently to ensure it is intact and functioning. SIDS sudden infant death syndrome Sudden death of an infant under age 1 with unexplained cause of death after complete investigation There is no way to predict or prevent SIDS                             Premature Low birth weight Multiples Race Age (2-4 months most often affected) Season History of respiratory difficulty Sleeping on stomach Infant risk factors for SIDS Maternal risk factors for SIDS Young mother <20 years Smoker or drug use Anemia Multiple pregnancies with short intervals between births History of another child with SIDS Low socioeconomic status Lack of prenatal care Nursing management Death is confirmed in the Emergency department. Nursing role is to support and reassure the family. Contact other family members for support, refer to organizations that can help grieving families. Reassure siblings that it will not happen to them, and that they did nothing to cause the SIDS. Community education regarding SIDS In the community, nurses need to educate. Promote the “Back to sleep” campaign. There has been a significant decrease in SIDS deaths since the AAP recommended children sleep on their backs Upper Respiratory Infection (URI)         Causes Symptoms Diagnosis and treatment Nursing management Medications Decongestants: phenylephrine (topical), pseudophedrine. Cause vasoconstriction and decrease nasal congestion and edema.            Short duration, can have rebound effect with topicals if used for too long. (Rhinitis medicomentosa) Contraindications: HTN, heart disease, MAOIs, prostate enlargement, thyroid disease Antihistamines: brompheniramine, chlorpheniramine, loratadine, fexofenadine, others. Newer ones are non sedating. Often mixed with decongestant. Nursing management Humidifiers Antipyretics Encourage fluids but don’t force eating no strenuous activity until well stress germ control Causes Symptoms Testing treatment Sinusitis Complications               Periorbital cellulites or abcess Cavernous sinus thrombosis osteomeylitis Meningitis Brain abcess Sepsis Hearing loss from eustachean tube edema Surgical intervention Endoscopic surgery Caldwell-Luc procedure-more invasive Antral irrigation-done in office under local anesthesia Nursing Diagnoses Pain Imbalanced nutrition: less than body requirements-due to decreased sense of smell, pain Nursing management children need to be evaluated if they have persistent purulent drainage and fever   If patient is placed on antibiotics, reinforce that they need to finish the course Treatments for URI will help with comfort level for both adults and children Pharyngitis Acute pharyngitis is an infection of the tonsils and throat. Most often caused by a virus, but can be caused by a bacteria. Most bacterial infections of the throat are “Strep throat” caused by group A beta-hemolytic streptococcus Culture is the only way to accurately diagnose Tonsillitis infection/inflammation of tonsils-may be viral or bacterial-usually due to strep A sore throat is not always tonsillitis Chronic tonsillitis=frequent throat infections with breathing and swallowing difficulty, persistent redness of anterior pillars, cervical lymphadenopathy “Strep” throat Classic strep symptoms: sore throat, headache, upset stomach, fever Physical exam findings: red throat, lymphadenopathy, fever  Signs/symptoms of pharyngitis and tonsillitis and treatment Bacterial Viral Treatment Warning signs if patient can not swallow, is drooling, is complaining of excessive pain, appears dehydrated or is in respiratory distress, they need immediate emergency attention Serious complications peritonsilar abcess- 1-3% Acute glomerulonephritis (7-10 days post infection) Rheumatic fever: (3-5 weeks post acute infection) Cervical adenitis Meningitis Surgery Peritonsillar abcess needs I&D                        Tonsillectomy-Surgery if at least 3 infections annually for 3 years. Not done on children under 3 due to risk of hypertrophy of lymphoid tissue. Surgery is also done if there is chronic tonsillitis, obstructive sleep apnea, or if tonsils interfere with sleep or facial development. Adenoids removed if needed-mouth breather, cough, impaired taste/smell, muffled voice, chronic otitis media Nursing managment History and physical-need to differentiate between normal sized tonsills and inflammed tonsills 1+ tonsills have visible gap between, 4+ tonsills are touching at midline Stress importance of completing full course of antibiotics Nursing care for the patient with tonsillectomy ensure patent airway, semi-fowler’s position, ice collar for pain and swelling if child: help parents and child prepare for surgery and possible overnight stay to surgery No herbal supplements prior to surgery Prior to surgery: no aspirin or ibuprofen for 2 weeks prior to surgery-assess bleeding time-bleeding is a big risk in this surgery No sore throat, fever or URI symptoms for at least 1 week prior Discharge planning Parents should anticipate a sore throat for 7-10 days post op Teach pain management, fluid and nutritional intake, restrictions on activity Discuss possibility of ear pain with swallowing days 4-8 post op Fluids, fluids, fluids, advance to soft diet as tolerated Go back to school 10 days post op Does not need to be in bed, but should avoid vigorous exercise for at least the first week Influenza Highly contagious viral respiratory disease-symptoms include rhinorrhea, fever, cough, headache and malaise. Occurs in epidemics every 1-3 years                        Occurs in winter months Transmission: airborne droplet and direct contact 3 viruses isolated: influenza A, B and C. Influenza A is the cause of most cases incubation is 18-72 hours viral pneumonia develops within 48 hours, and can cause hypoxemia and death within days Reye’s syndrome is a rare complication-develops within 2-3 weeks of influenza infection, 30% mortality rate. Causes hepatic failure and encephalopathy in affected patients. Diagnosis History, physical Chest xray CB C Viral culture to confirm diagnosis Prevention: immunization Treatment Not treatable with antibiotics Amantadine (Symmetrel) or rimantadine (Flumadine) can be given as prophylaxis to exposed persons who are unvaccinated Can also be used to treat patients with influenza virus to shorten the course of illness OTC meds Epiglotitis Laryngitis Diptheria Pertussis Laryngeal infection              Epiglotitis     MEDICAL EMERGENCY!!!!! Common in children, not adults H. influenza is most common pathogen Rapidly progressing cellulitis-airway is compromised quickly History   1-2 day history of uri with sore throat Complains of dysphonia, dysphagia, drooling            Children have respiratory stridor, barking cough, hoarseness Children have high fever >102.2 Prefers upright position-tripod position with chin thrust Diagnosis of epiglotitis DO NOT use tongue blade if epiglotitis is susupected Diagnosed by flexible fiberoptic laryngoscopic exam Xray of soft tissues of the neck Treatment ICU May require nasotracheal intubation to maintain airway IV antibiotics-usually cephalopsorin or penicillin Dexamethasone (systemic corticosteriod) given to help reduce swelling of the airway Nursing care Monitor and maintain patent airway Observe for signs of respiratory distress or airway obstructionnasal flaring, stridor, restlessness, accessory muscle use, decreased O2 saturation KEEP EMERGENCY SUPPLIES AVAILABLE AT ALL TIMES Causes Treatment Nursing care LARYNGITIS           Diptheria and Pertussis Acute contagious disease spread by Corynebacterium diptheriae, spread by droplets or exposure to contaminated surfaces Highly contagious acute URI caused by Bordetella pertussisspread by respiratory droplets-”whooping cough” Not usually seen in US due to good immunization Can be seen in people from other countries where immunization is not as common Pathophysiology & Complications    Both infect the mucous membranes of the respiratory tract Diptheria has thick grey pseudomembrane which bleeds when removed, can cause cardiac or neuro complications Pertussis is whooping cough, vomiting after cough is common                     Diagnosis & Treatment Confirmed by culture Both treated with antibiotics-penicillin or erythromycin for diptheria, erythromycin for pertussis Immunize contacts Nurses can encourage compliance with immunization Encourage patients to seek care for uri symptoms that seem severe or are prolonged Epistaxis Causes Pathophysiology Treatment Medical management Topical vasoconstrictors (cocaine 0.5%, phenylephrine (neo synephrine) Chemical cautery-silver nitrate or gelfoam Packing Anterior nose bleed-packing for 24-72 hours Posterior nose bleed-packing left in place for 2-3 days, risk of respiratory or cardiac complications Surgery is another option-bleeding vessel is visualized and cauterized Surgery is preferable to posterior packing Anxiety Risk for aspiration Assessment Calm patient Teach patient how to control bleeding with pressure If packing is present-assess for placement, assess patient for adverse reactions to packing Nasal trauma/surgery Nursing diagnoses and care    Broken nose is most common trauma, bilateral >unilateral Accompanied by soft tissue injury, black eyes, bony crepitus Rhinoplasty most common surgery-done to repair damage from a trauma or elective by patient Complications of fracture    Septal deviation common after fracture Septal hematoma, abcess formation, nasal obstruction common If there is accompanying facial trauma, dura may be compromised, and CSF may be leaking-presents as rhinorrhea but tests positive for glucose if CSF Head and facial xrays Intranasal exam with nasal speculum to rule out septal hematoma Goal of treatment-maintain airway, prevent deformity Treatment    Early reduction (may be done in ER), may be splinted Surgery for complex nasal fractures, septal deviation, or persistent CSF leakage Rhinoplasty: surgical reconstruction of the nose. Relieves airway obstruction and repairs deformity- surgery may be delayed if swelling is severe Nursing diagnosis and care           ineffective airway clearance Risk for infection health promotion patient education-wear helmets, seatbelts, face protectors ice- 20 minutes qid Rest head elevation swelling and bruising will gradually disappear-swelling first, bruising may last several weeks avoid straining to report signs of infection-stiff neck, headache, fever, immediately Laryngeal obstruction or trauma   larynx is narrowest portion of the airway obstruction is life threatening emergency treatment Diagnosis          can occur with head and neck trauma Treatment of laryngeal obstruction or trauma Goal is to maintain open airway Treatment with epinephrine if anaphylaxis CT scan if fracture is suspected, make sure airway is maintained first Soft tissue injury managed with humidifier, IV fluids, antibiotics, corticosteroids Severe injuries require endotrachial intubation or immediate tracheostomy Nursing Care Priority is establishing open airway Observe at risk patients for signs of laryngeal obstruction Suction airway when needed Be prepared to perform the Heimlich, or assist with emergency intubation if needed Provide emotional support and education for patient and family Sleep apnea             Definition: intermittent absence of airflow through mouth and nose during sleep Most often affects middle aged adults (more common in men), potentially life threatening Leading cause of excessive daytime sleepiness (somulence) Sleep apnea comes in 2 forms Obstructive sleep apnea Central sleep apnea Goal of treatment is to restore normal airflow and prevent adverse effects Risk factors Male Age Obesity Neck circumference >17 inches in men, >16 inches in women ETOH use CNS depressants Obstructive sleep apnea        Pathophysiology     Skeletal muscle tone decreases during sleep Drop in O2 saturation, PO2, pH, rise in pCO2 Progressive asphyxia results in brief arousal from sleep-airway patency and flow are resotred. Can occur 100s of times per night Secondary physiologic effects    Daytime sleepiness Impaired intellect Memory loss, personality changes Manifestations         Loud snoring during sleep Periods of apnea observed by bed partner Gasping for air during sleep Excessive daytime sleepiness Headache, irritability, restless sleep Difficulty thinking Impotence Hypertension Diagnostic testing      Polysomnography (overnight sleep study) Electroencephalogram done, as well as ocular movements and muscle tone Respirations observed and recorded Continuous oxygen saturation readings Heart rate Treatment of mild to moderate sleep apnea        Weight reduction-often cures disorder, but is hard to maintain Avoidance of ETOH Improving nasal patency Avoid supine sleeping Use of oral appliances to keep tongue and jaw in proper position Treatment of choice CPAP (nasal continuous positive airway pressure) Air compressor with tight fitting nasal mask   Keeps the airway open BiPap is a newer system-provides higher pressures during inhalation and lower pressures during exhalation Surgical treatment    tonsillectomy and adenoidectomy Uvulopolotopharyngoplasty (UPPP)-successful 50% of the timeworks when tissue osbstruction from soft palate, uvula and posterior lateral pharyngeal wall is contributing to the problem Tracheostomy in severe cases Nursing diagnoses       Disturbed sleep pattern Fatigue Ineffective breathing pattern Impaired gas exchange Risk for injury Risk for sexual dysfunction (impotence) Nursing care     Usually treated at home nursing care involves education of the patient and family about equipment and decreasing risk factors Refer patient and family to support group Humidification of air with CPAP machine Nasal polyps      Benign grape like growths on the mucous membrane lining of the nose-can get very large Can lead to sinusitis Occur in people with chronic allergies and asthma voice may sound nasal **asthmatics with nasal polyps are likely to have aspirin allergythey may not be aware** Medical treatment  may resolve if associated with URI    can be treated with steroids, but will grow when steroids are stopped surgery may be required-done in physician’s office with local anesthetic. Polyps do recur, multiple surgeries may be necessary Nursing care      Teach post op home careIce to decrease swelling, promote comfort, prevent bleeding Don’t blow nose for 24-48 hours after packing is removed Avoid straining, coughing, strenuous exercise for at least 2-3 days Oral care and increased fluids Laryngeal tumors       Benign malignant Benign Papillomas, nodules, polyps Appear in people who shout, overuse voice, speak in abnormally high or low tones Referred to as singer’s nodules-common in anyone who uses their voice a lot-singers, cheerleaders, public speakers Irritation from pollutants or cigarette smoke also lead to polyps Malignant       Uncommon-curable if detected early Men are affected more often than women Cancer usually develops between the age of 50 & 70 Smoking is a major risk factor, increasing risk 5 to 35 times ETOH consumption with smoking increases risk up to 100 times Exposure to pollutants, HPV, poor nutrition and race also factor in Pathophysiology of benign tumors Benign-papillomas are small wart-like growths that are viral in nature Polyps and nodules develop due to voice abuse Nodules are paired lesions on the edges of the vocal cords Hoarseness and breathy quality of voice are manifestations of benign vocal cord tumors     Pathophysiology of malignant tumors      Squamous cell ca is the most common type -develop over several years Precancerous lesions-white patchy lesions visible in the mouthleukoplakia Later stages-erythroplakia-red velvety patches Initial cancer is cancer in situ (CIS)-it is superficial, and about 30% will progress to squamous cell cancer if left untreated Spreads by direct invasion of surrounding tissue and metastisismets to lungs, other sites are rare Glottis Supraglottis subglottis Sites of malignancies       Cancer of the glottis 65% of laryngeal cancers-well differentiated and slow growing metastisis occurs late due to limited lymph supply symptoms: hoarseness or voice change-if persistent, needs evaluation Cancer in the supraglottic area 35% of all laryngeal cancers there is a large lymph supply in this area-tumors invade locally and metastasize quickly symptoms don’t usually develop until tumor is large-patients complain of painful swallowing, lump in throat, sore throat that does not resolve late symptoms include: dyspnea, bad breath, and pain that radiates to the ear Sub-glottic tumors   least common often asymptomatic until tumor is so large that it blocks the airway diagnosis Direct or indirect laryngoscopy-used for initial evaluation. Fiberoptic scope used for direct, mirrors used for indirect exam Biopsy: obtained under general anesthesia. Obtained by fine needle aspiration or during edoscopy          Imaging: CT, MRI, chest xray Used to evaluate size of mass, involvement of lymph nodes, metastasis to lungs Barium swallow may be done to evaluate swallowing Treatment of benign lesions   Benign: inhaled steroid spray for vocal cord polyps Surgical excision sometimes needed-done via laryngoscopy using forceps or laser-sent for biopsy Treatment of malignant lesions      depends on tumor staging and presence of mets Choices are: Radiation Chemotherapy surgery Radiation     Radiation therapy-treatment of choice for early cancers, especially glottic cancer Works well in combination with chemo for more advanced laryngeal cancers Survival rates often the same as with surgery Radiation may also be used in conjunction with surgery to destroy remaining cells, or as palliative care, sometimes used to shrink tumors pre-op Chemotherapy    Used in combination with radiation to treat some laryngeal cancers Used to treat metastasis and for palliative care when tumors are not operable Multiple drugs often used to increase treatment success rate Surgery     Type of surgery is determined by type, size, location and invasiveness of tumor Goals of surgery: Remove tumor Maintain airway patency  Maintain optimal cosmetic appearance Laser during laryngoscopy       Used to remove carcinoma in situ, vocal cord polyps, early vocal cord cancers Excellent cure rate Voice is preserved, but often changed Outpatient procedure Voice rest post op Temporary tracheostomy sometimes needed-once removed, patient can eat, speak and breathe normally Laryngectomy        Partial: used for tumors localized to a portion of the larynx with limited extension beyond larynx 50% or more of the larynx is removed voice is preserved temporary tracheostomy may be needed for 5-7 days post op aspiration is a risk tube feedings or TPN may be needed for several weeks patient needs to be taught swallowing techniques to prevent aspiration Total laryngectomy      treatment for cancers that extend beyond the vocal cords entire larynx is removed, as well as the epiglottis, thyroid cartilage, trachea rings, and the hyoid bone no risk for aspiration normal speech is gone need for permanent tracheostomy Radical neck dissection   if cervical lymph nodes are affected, but no evidence of distal mets all soft tissue from the lower edge of the jaw down to the clavicle is removed-this includes cervical lymph nodes, sternocleidomastiod muscle, internal jugular vein, cranial nerve XI, and submaxillary salivary gland skin grafts or flaps needed to close the wound-significant deformity present after surgery    hemovac drains in place post op client will have difficulty lifting or turning head post op due to muscle loss, shoulder droops on affected side Modified neck dissection  sternocleidomastiod muscle, internal jugular vein and spinal accessory nerve remain intact Pre-op care     patient education establish post op communication means inform patient that sense of taste and smell will be affected, alternate forms of nutrition needed in the post op period assess psychological readiness-big body image changes Post op care       maintain patent airway-very important in immediate post op period pain control, meds, cold paks elevate head of bed suction ensure adequate fluid intake and proper nutrition-withhold food until gag reflex returns-taste will be altered infection control Speech rehabilitation    Tracheoesophageal puncture (TEP) esophageal speech Artificial devices Nursing care   Health promotion Prevention-focus on smoking cessation and avoidance or decreased use of alcohol Nursing assessment   Be familiar with warning signs of laryngeal cancer-voice changes, persistent lump in throat, persistent sore throat History and physical  Prevention-discuss tobacco and alcohol use with patient Nursing diagnoses     Impaired verbal communication Impaired swallowing imbalanced nutrition; less than body requirements Anticipatory grieving Going home        Voice care-no shouting Discuss treatment options Speech alternatives-only 30% master esophageal speech Smoking cessation and alcohol abstince Nutrition support Humidify air Stoma care and trach care