Common radiologic term:

A radiolucent (dark) area surrounded by dense tissue (white). A cavity is the hallmark of a lung abscess. A fluid level may been seen inside a cavity

Common radiologic term:

The act of becoming solid; commonly used to describe the solidification of the lung caused by a pathologic engorgement of the alveoli, as occurs in acute pneumonia

Common radiologic term:

Any poorly defined radiodensity (white area); commonly used to describe an inflammatory lesion

Common radiologic term:

Any pathologic or traumatic alteration of tissue or loss of function of a part

Common radiologic term:

State of being opaque (white); an opaque area or spot; impervious to light rays

Common radiologic term:

A lesion in the lung that is 6cm or more in diameter; commonly used to describe a pulmonary tumor

Common radiologic term:

A lesion in the lung that is less than 6cm in diameter and composed of dense tissue

Before undergo chest x-ray, ask woman of reproductive age if they could be (?) and avoid radiation exposure

When undergoing chest x-ray, what equipments should staff need?

1. Lead panels

2. Lead aprons

3. Thyroid shields

4. PPE

Allergy tests, Skin prick test:

Read the result after (?) mins pricking

Allergy tests, Skin prick test:

Positive: wheal size (?) than negative

Allergy tests, Intradermal skin test:

Positive: wheal size (?) than control

SPIROMETRY/ PULMONARY FUNCTION TESTS:

Forced expiratory volume in 1 second, volume of air forcibly expired from a maximum inspiratory effort in the first second

SPIROMETRY/ PULMONARY FUNCTION TESTS:

Forced vital capacity; the total volume that can be forcefully expired from a maximum inspiratory effort

SPIROMETRY/ PULMONARY FUNCTION TESTS:

• Patients cannot fully fill their lungs with air, i.e. their lungs are restricted from fully expanding.

• Decreased FEV1 and FVC

• FEV1/ FVC is normal or increased

SPIROMETRY/ PULMONARY FUNCTION TESTS:

• Patients cannot fully exhale all the air from the lungs.

• Decreased FEV1, FVC and FEV1/FVC

SPIROMETRY/ PULMONARY FUNCTION TESTS, Related nursing interventions:

• Activities should preferably be avoided: Smoking within ?

SPIROMETRY/ PULMONARY FUNCTION TESTS, Related nursing interventions:

• Activities should preferably be avoided: Consuming alcohol within ?

SPIROMETRY/ PULMONARY FUNCTION TESTS, Related nursing interventions:

• Activities should preferably be avoided: Performing vigorous exercise within ?

SPIROMETRY/ PULMONARY FUNCTION TESTS, Related nursing interventions:

• Activities should preferably be avoided: Eating a large meal within ?

SPIROMETRY/ PULMONARY FUNCTION TESTS, Related nursing interventions:

Withhold medications: (?) for at least 4 hours

SPIROMETRY/ PULMONARY FUNCTION TESTS, Related nursing interventions:

Withhold medications: (?) should be withheld according to departmental policy

ARTERIAL BLOOD GAS (ABG):

Measurement of ?

1. blood pH

2. arterial O2

3. CO2 tensions

Can we use the ABG sample which with air bubble in it?

ARTERIAL BLOOD GAS (ABG):

Human blood normally has a pH of ?

BRONCHOSCOPY:

• Enables a “liquid lung biopsy” from the distal airways and alveoli.

• Secretions are aspirated from large airways directly or following the instillation of 10 to 30 ml sterile saline.

BRONCHOSCOPY:

• Used to collect cells from the airways to enable diagnosis of diffuse disease, visible airway mucosal abnormalities, peripheral lesions or peripheral lung infiltrates.

• Used to reveal lung cancer, inflammation and infections

BRONCHOSCOPY:

• Obtain biopsies of visible endobronchial lesions or mucosa by forcep.

• The forceps are opened and applied directly to the lesion using gentle, firm pressure.

• As tissue is engaged, the forceps are closed and "tugged" before being withdrawn through the bronchoscope.

BRONCHOSCOPY:

• Performed by selecting the segmental bronchus through which the forceps are to be passed.

• The forceps are anchored at the bifurcation of a respiratory bronchiole, closed, and then tugged.

• A sample of lung parenchyma is obtained by effectively tearing respiratory bronchioles.

BRONCHOSCOPY:

• Can be applied to visible endobronchial lesions.

• A syringe allowing for a small footprint to minimise bleeding.

• Allows for depth of the given lesion for a more representative cytology sample.

BRONCHOSCOPY:

• Can be performed in the central or peripheral lung area.

• Needle penetrate the bronchial wall and enter a mass or tumor.

BRONCHOSCOPY:

• A bronchoscopic technique that uses ultrasound to visualize structures within the airway wall, lung, and mediastinum.

• EBUS in combination with transbronchial needle aspiration (EBUS-TBNA) is most commonly used as a tool to diagnose, stage patients with suspected or known non small cell lung cancer (NSCLC).

• It can also be used to sample mediastinal lymphadenopathy of unknown etiology, mediastinal masses, pulmonary nodules, and endobronchial or peribronchial lesions.

BRONCHOSCOPY, Pre-medication:

• Intramuscularly is given 30 minutes before the procedure to reduce the secretions and vasovagal events

BRONCHOSCOPY, Pre-medication:

• Usually given to reduce the anxiety

BRONCHOSCOPY, Pre-medication:

• Local anesthesia of the upper and lower airways

Definition:

A localized, protective reaction of tissue to injury, irritation, or infection, manifested by pain, redness, heat, swelling, and sometimes loss of function

Definition:

indicates a host interaction with an organism. Infections can be caused by microorganisms such as viruses, bacteria, and larger organisms like parasites and fungi

Definition:

Communicable, or infectious diseases, are caused by microorganisms such as bacteria, viruses, parasites and fungi that can be spread, directly or indirectly, from one person to another.

What disease

• is a single stranded, RNA virus

• causes respiratory tract disease such as infection of the airway, lungs & middle ear

• It is the most common cause of bronchiolitis and pneumonia for those under 1 year of age

• may cause death in infants

• In older children and adults, the disease may only be mild

2 immunization options available for protecting infants against RSV:

for the pregnant woman

2 immunization options available for protecting infants against RSV:

given to the baby.

Management of Seasonal Influenza:

➢ for treating flu in those over 2 weeks of age and preventing flu in people one year of age and older

➢ is taken by mouth

Management of Seasonal Influenza:

➢ is for treating flu in people 7 years and older and for preventing flu in people 5 years and older

➢ is inhaled through the mouth

Classification of Pneumonia:

• Defined as an infection begins outside the hospital or is diagnosed within 48 hours after admission

• Either bacterial or viral

• Streptococcus pneumoniae, Haemophilus influenza , Mycoplasma pneumoniae

Classification of Pneumonia:

• Also named as nosocomial pneumonia / Healthcare associated pneumonia

• Defined as infection that is not present on admission and occurs 48 hours or more after admission

• 90% bacterial & more difficult to treat due to antibiotic resistance

• Pseudomonas aeruginosa, Staphylococcus aureus, Klebsiella pneumoniae, Escherichia Coli

Situations increase the risk of infection:

• Stagnant water in water system

• Old water distribution or plumbing systems

• Living near cooling towers or fountains

• Using electric water heater, humidifiers, whirlpool spas or hot water spring spas

• Recent stay in hotels or ships

• Aspiration of contaminated water or ice, particularly in susceptible hospital patient

• Exposure of babies during water births

Mode of Transmission:

• Mode of transmission still uncertain

• could be spread from person-to-person through close contact

• People may be infected upon exposure to animals (especially camel), environment or other confirmed patients (such as in a hospital setting)

• Secondary cases involve mainly healthcare workers, who were in close contact with or providing unprotected care to patients with MERS-CoV infection

Middle East Respiratory Syndrome Coronavirus (MERS-CoV) is a (?) coronavirus which has not been identified in humans before and is different from other coronaviruses (including SARS-coronavirus) that have been found in humans or animals.

Tuberculin Skin Test (Mantoux Method):

negative and no treatment indicated

Tuberculin Skin Test (Mantoux Method):

positive in situation of HIV infection, contact with infectious TB case within past 2 years, fibrotic opacities on chest x-ray consistent with untreated but healed TB, severely immunosuppressed patients

Tuberculin Skin Test (Mantoux Method):

positive in situation of TST conversion within 2 years

1st line Medications: 4- or 6-month Regimen:

1. Isoniazid

2. Rifampicin

3. Pyrazinamide

4. Ethambutol

1st line Medications:

• 15-30mg/kg (2g max. daily), bactericidal

• Taken with meal to reduce GI upset

• Monitor liver function test (LFT)

• Monitor level of uric acid

• Adverse Effect

✓Nausea & vomiting

✓Anorexia

✓Photosensitivity

✓Jaundice, hepatotoxicity

✓Skin rash

✓Arthralgia

✓Hyperuricemia

Infection Control Measure:

• Evidence for containment of infectivity: In the absence of rifampicin resistance, patient has received and tolerated standard multi-drug anti-tuberculosis treatment

• For at least 14 days with demonstrated clinical improvement

AND/OR

• Two or more consecutive negative AFB smear results from adequately collected sputum specimens (8-24 hour intervals, preferably with at least one specimen being an early morning specimen)

Infection Control Measure:

⮚ The case will be placed in the same cubicle/room with immunocompromised patients after deisolation.

⮚ Laryngeal TB

⮚ Extensive pulmonary involvement or cavitatory TB

• Discontinuation isolation after completing 2 weeks of treatment with clinical improvement and sputum smear conversion

Infection Control Measure:

• Until three negative smears at weekly intervals (ideally have a negative culture)

• For those whose symptoms have improved and who are unable to produce sputum, discharge

• Decisions taken by the multidisciplinary team

Management of Worsening Asthma and Exacerbations:

1. Viral respiratory infections e.g. rhinovirus, influenza, adenovirus, pertussis, RSV

2. Allergen exposure Grass pollen, soybean dust, fungal spores

3. Food allergy

4. Outdoor air pollution

5. Seasonal changes

6. Poor adherence with ICS

Nursing Intervention: Ineffective airway clearance

Monitor skin colour and temperature and level of consciousness, e.g. Cyanosis, cool clammy skin, and changes in level of consciousness

What is the rationale?

Nursing Intervention: Ineffective airway clearance

Assess arterial blood gas results and pulse oximetry readings;

What is the rationale?

Nursing Intervention: Ineffective airway clearance

notify the physician of abnormal values or changes in status.

What is the rationale?

Nursing Intervention: Ineffective airway clearance

Assess cough effort and sputum for colour, consistency, and amount.

What is the rationale?

Nursing Intervention: Ineffective airway clearance

Place in Fowler’s, high-Fowler’s, or orthopneic position to facilitate breathing and lung expansion.

What is the rationale?

Nursing Intervention: Ineffective airway clearance

Administer oxygen as ordered.

What is the rationale?

Nursing Intervention: Ineffective airway clearance

Initiate or assist with chest physiotherapy, including percussion and postural drainage.

What is the rationale?

Nursing Intervention: Ineffective airway clearance

Increase fluid intake.

What is the rationale?

Nursing Intervention: Ineffective airway clearance

Provide suctioning as needed.

What is the rationale?

Tuberculin Skin Test:

(?) ml of Tubercle bacillus extract (tuberculin) purified protein derivative (PPD) is injected to intradermal layer in tuberculin syringe with 26- 27 gauge needle

Tuberculin Skin Test:

Into the dorsal aspect of the (?)

Tuberculin Skin Test:

The test is read (?) hours after injection

Tuberculin Skin Test:

An induration (not erythema) of > (?)mm : positive reaction

Preventive Measures in the Community:

• Prompt identification & treatment limits the spread of infection

• Treatment regime should be in adequate dose, proper combination, continuous and prolonged treatment

Preventive Measures in the Community:

• Educate through the mass media advising people who have been coughing about 4 weeks should be examined for tuberculosis by chest X-ray and sputum examination

Preventive Measures in the Community:

• According to the Prevention and Control of Disease Ordinance (Cap.599) in HK, a medical practitioner who makes a diagnosis of TB should notification the case to the Director of Health

• Notify new cases to Department of Health

• The contacts are examined at the chest clinics with CXR taken

• For child contacts, tuberculin test is also given

Preventive Measures in the Community:

• The Bacille Calmette-Guérin (BCG) vaccine is a live attenuated strain of Mycobacterium bovis

• Effective in prevention of TB meningitis and disseminated TB in infants and young children

• Started in Hong Kong in 1952 for all infants within 24 hours after birth

• Vaccine can be received before age 15

• 75% protection for 15 years

Preventive Measures in the Community:

• Keeping only tuberculosis free herds & slaughtering tuberculosis cattle & by pasteurization of milk

Preventive Measures in the Community:

• By raising living standard, maintain personal hygiene, maintain optimal nutritional state & proper housing

• Improvement of environmental hygiene, e.g. town planning, recreational activities, food inspection, fresh water supplies, sanitation facilities

Preventive Measures in the Community:

• Mass publicity to increase community awareness of TB. e.g. clinical manifestation of disease, source of help, value of adequate rest & exercise, fresh air & nutritious diet

• Give health education to the public, e.g. anti-splitting, immunization program

• Emphasize the important of seeking early treatment & make known of the treatment provided

 A machine that creates a mist of medication, which is then breathed in through a mask or mouthpiece

 Commonly used to give high doses of reliever medication in an emergency situation or in children

 Use according to infection control guidelines

CLINICAL MANIFESTATIONS of COPD:

1. Chronic cough:

Usually the initial symptom

Frequently a morning cough, thenbecomes constant

Usually productive

2. Productive sputum: sputum quality may change with exacerbations or superimposed infection

3. Dyspnoea:

Initially with exercise but may progress to dyspnea even at rest

Difficulty speaking in full sentences.

CLINICAL MANIFESTATIONS of COPD:

 Barrel Chest

 Hyper-resonance on percussion

 Barrel chest caused by chronic hyperinflation

 Supraclavicular fossae retraction on inspiration

 Coarse crackles

 Distant breath sound/wheezing/poor air movement on auscultation

Other symptoms of COPD:

1. Lower-extremity swelling

2. Fatigue

3. Weight loss

4. Cyanosis

5. Clubbing

CLASSIFICATION of COPD:

If Pre-Bronchodilator FEV1/FVC ＜ 0.7

CLASSIFICATION of COPD:

If Post-Bronchodilator FEV1/FVC ＜ 0.7

CLASSIFICATION of COPD:

If Post-Bronchodilator FEV1/FVC ≥ 0.7

CLASSIFICATION of COPD:

FEV1 ≥ 80% predicted

CLASSIFICATION of COPD:

50% ≤ FEV1 < 80% predicted

CLASSIFICATION of COPD:

30% ≤ FEV1 < 50% predicted

CLASSIFICATION of COPD:

FEV1 <30% predicted

MEDICATION - bronchodilator:

1. Anoro: Umeclidinium bromide + Vilanterol

2. 2. Duaklir: Aclidinium bromide + Formoterol fumarate dihydrate

3. 3. Spiolto: Tiotropium + Olodaterol

4. 4. Ultibro: Indacaterol + Glycopyrronium

MEDICATION - bronchodilator:

1. Symbicort: Budesonide + Formoterol

2. 2. Vannair: Budesonide + formoterol fumarate dihydrate

MEDICATION - bronchodilator:

1. Seretide: Salmeterol + Fluticasone Propionate

2. 2. Flutiform: Fluticasone propionate + Formoterol fumarate dihydrate

3. 3. Relvar: Fluticasone furoate + Vilanterol trifenatate

MEDICATION - bronchodilator:

1. Trelegy: Fluticasone furoate + Umeclidinium + Vilanterol

MANAGEMENT – PHARMACOLOGICAL, COPD:

≥2 moderate exacerbations or ≥1 leading to hospitalization

MANAGEMENT – PHARMACOLOGICAL, COPD:

0 or 1 moderate exacerbations (not leading to hospitalization)

mMRC 0-1

CAT < 10

MANAGEMENT – PHARMACOLOGICAL, COPD:

0 or 1 moderate exacerbations (not leading to hospitalization)

mMRC ≥ 2

CAT ≥ 10

Which are the risk factors of CA lung?

1. Tobacco

2. Second hand smoke

3. Ageing (age > 50)

4. Radiation

5. Pollution

CLASSIFICATION of CA lung:

1. Adenocarcinoma

2. Squamous cell carcinoma

3. Large cell carcinoma

CLASSIFICATION of CA lung:

tend to arise in the large airways in the lungs and develop from basal cells

CLASSIFICATION of CA lung:

arise from alveolar cells located in glands

CLASSIFICATION of CA lung:

arise from neuroendocrine cells

CLASSIFICATION of CA lung:

• Very rapid growth rate to form large tumours

• Central in origin, spread to the lymph nodes and to other organs (i.e. brain, liver, and bones)

• >40% of patients have distant metastasis at time of presentation

CLASSIFICATION of CA lung:

• Occurs more frequently in women, in non-smokers, and in Asians

• Commonly found in peripheral regions

• Epidermal growth factor receptor (EGFR) mutations are also common

• Moderate growth rate

CLASSIFICATION of CA lung:

• Growth rate is slow

• Obstructive manifestation are non-specific

CLASSIFICATION of CA lung:

• Rapid growth rate

SURGERY for CA lung:

• Removal of a small section (section) of peripheral lung tissue

SURGERY for CA lung:

• Removes peripheral lung tumour without extension to the chest wall or metastasis

• Chest tube is placed by the end of operation to remove air and blood

SURGERY for CA lung:

• For tumour confined to a single lobe:

1. The remaining lung tissues will expand to fill the space previously occupied by diseased lung tissue

2. Chest tubes will be placed at the end of operation

• Sleeve resection: removal of a cancerous lobe along with part of the bronchus attaching to it, with reconstruction of the remaining bronchus

SURGERY for CA lung:

• Indicated for tumour widespread throughout the lung, involving the main bronchus or spread/ fixed to the hilum

• Anatomical change after pneumonectomy:

1. Elevation of hemidiaphragm on operative side

2. Hyperinflation of the remaining lung

• Chest tube may be placed after the operation for monitoring of bleeding

CHEST TRAUMA:

• Results from sudden compression or positive pressure inflicted to the chest wall, e.g. motor vehicle crashes, falls, and bicycle crashes

• Types of this chest trauma include chest wall fractures, dislocations, and barotraumas; injuries of the pleural, lungs, and aerodigestive tracts; and blunt injuries of the heart, great arteries, veins, and lymphatics.

CHEST TRAUMA:

• Any organ or structure within the chest is potentially susceptible to traumatic penetration, e.g. gunshot, and stab injury

• The clinical consequence of this trauma to the chest depends on the mechanism of injury, location, associated injuries, and underlying illness

CHEST TRAUMA, Management:

• Postural drainage, physiotherapy and suctioning are used to remove the secretions

• Adequate hydration is important to mobilize secretions

CHEST TRAUMA, Management:

• Controlling bleeding

• Restoring body fluid volume for preventing hypovolemic shock

• Restoring negative intra-pleural pressure and draining intra-pleural fluid and blood by chest tube

• For open sucking wounds, apply occlusive dressing and tape on 3 sides to allow air escape and prevent air entry, chest tube placement follows

CHEST TRAUMA, Management:

• Establishing oxygen support/ intubation/ mechanical ventilatory support

CHEST TRAUMA, Management:

• Pain in managed by intercostal nerve blocks/ opioids via PCA or other methods.

Classification of PNEUMOTHORAX:

• occurs when air escapes from a laceration in the lung itself and enters the pleural space or form a wound in chest wall

• may result from blunt trauma (e.g. rib fractures) and penetrating chest (e.g. stab wounds or gunshot wounds)

• is often accompanied by haemothorax; often both blood and air are found in the chest cavity after a major trauma

Classification of PNEUMOTHORAX:

• resulting from complication of a medical procedure:

1. puncture of the lung during needle aspiration lung biopsy

2. thoracentesis

3. central venous catheter placement

Classification of Traumatic pneumothorax:

• gas in the pleural space is not in direct contact with the atmosphere

• caused by air leaking into the pleural space from a defect in the lung parenchyma, i.e. perforation of the visceral pleura with the parietal pleura remain intact

• the pleural pressure will increase -> prevents lung expansion during normal inspiration

Classification of Traumatic pneumothorax:

• is a condition in which the pleural space is in direct contact with the atmosphere

• free communication between the exterior and the pleural space; occurs when there is an open defect in the chest wall

• air pressure in the pleural cavity becomes positive, the lung collapses on the affected side

• resulting in decreased total lung capacity, vital capacity, and lung compliance -> imbalances in the ventilation -perfusion ratio leading to hypoxia

PNEUMOTHORAX Management:

1. client with small SSP and clinically stable, observation is preferred

2. administration of high-flow O2 can accelerates resorption

3. monitor serial CXR

PNEUMOTHORAX Management:

1. aspiration of air from the pleural space with needle

2. maybe undertake in moderate or large pneumothorax

3. in tension pneumothorax, a large bore needle is inserted into the pleural space via the 2nd anterior ICS as an emergency measure)

PNEUMOTHORAX Management:

insertion of chest tube or pigtail catheter into the pleural space to remove air to restore the normal sub-atmospheric intra-pleural pressure to allow lung re-expansion

PNEUMOTHORAX Management:

1. obliteration of the pleural space by inducing pleural injury

2. pleural inflammation and fibrosis cause subsequent pleural adhesion, leading to obliteration of the pleural space

3. primarily indicated to prevent recurrence of spontaneous pneumothorax

4. Two types:

1. Chemical pleurodesis

2. Mechanical pleurodesis

PLEURAL EFFUSION:

■Normally, only a small amount of extracellular fluid (?)mL of fluid per kilogram of body weight) that lubricates the pleural surfaces

■An excess of fluid being accumulated in the pleural space a manifestation of underlying

disease condition

PLEURAL EFFUSION, Classification:

Occurs due to increase hydrostatic pressure or low plasma oncotic pressure

e.g. CHF, Cirrhosis, Nephrotic syndrome, PE, Hypoalbuminemia

PLEURAL EFFUSION, Classification:

Occurs due to inflammation and increased capillary permeavility

e.g. Pneumonia, Cancer, TB, Viral infection, PE, Autoimmune

INTERCOSTAL / CHEST DRAINAGE, Suction Chamber:

INTERCOSTAL / CHEST DRAINAGE, Suction Control Stopcock:

▪ The stopcock must be (?) for initial system setup and should NOT be turned (?) during patient use (on gravity drainage leave)

Common Clinical Manifestations of (?):

• Exertional dyspnoea

• Exercise intolerance

• Inspiratory crackles

• Clubbing of fingers & toes

• Diffuse, irregular or linear opacities in lower lobe of the CXR

• Respiratory failure & marked hypoxaemia (later stage)

Common Clinical Manifestations of (?):

• Severe dyspnoea, productive cough

• Nodular opacities in upper lungs

• Lymph node calcification

• Lower-lobe hyperinflation or bullae

• Cor-pulmonale or death (severe)

What disease?

• A fibronodular lung disease caused by inhaled silica particles (crystalline silica)

• Causes mineral deposits to form at the level of terminal bronchioles and alveoli

• Its prevalence increases significantly in the introduction of mechanized mining

What disease?

➢ progressive massive fibrosis

➢ result in expectoration of black sputum

➢ often result in dyspnoea, restrictive ventilatory defect (reduced lung volume), impaired gas

diffusion, and reduced life expectancy

Coal Worker’s Pneumoconiosis:

➢ characterized by multiple small nodular opacities on the CXR film

➢ asymptomatic

➢ not associated with any impairment of lung function or alteration to prognosis

Definition of Respiratory Failure:

• A decreased in PaO2 < 50-60mmHg (6.67-8 kPa)

Definition of Respiratory Failure:

• An increase in PaCO2 > 50mmHg (6.67 kPa)

Common Causes of Respiratory Failure:

1. Alveolar disorders: Pneumonia, Pneumonitis, COPD

2. Pulmonary oedema: Heart failure, Acute respiratory distress syndrome (ARDS), near-drowning

3. Ventilation-perfusion mismatch: Pulmonary embolism (PE)

Common Causes of Respiratory Failure:

1. Airway obstruction: Laryngospasm, Foreign body aspiration, airway oedema

2. Respiratory disease: Asthma, COPD

3. Neurological causes: Spinal cord injury, drug overdose, myasthenia gravis, stroke

4. Chest wall injury: Flail chest, pneumothorax

Classification of Respiratory Failure:

1. Failure of oxygenation leading to hypoxaemia with normocapnia

2. Hypoxaemia can occur due to:

-Impairment of oxygen diffusion

-Ventilation/perfusion mismatch (V/Q mismatch)*

-Shunt

Classification of Respiratory Failure:

1. Failure of ventilation resulting in hypoxaemia and predominant hypercapnia

2. Hypercapnia can occur due to:

-Alveolar hypoventilation

-Mechanisms for hypoxaemia

e.g. combination of alveolar hypoventilation and V/Q mismatch for COPD hypercapnia

Which can be acute?

• is a life-threatening deterioration of the ability of the lungs to perform one or both of the normal gas exchange functions of oxygenation and carbon dioxide removal.

• Results in inadequate oxygenation of the blood and inadequate perfusion of vital organs

• Can be Type I or Type II respiratory failure with a concurrent acidotic arterial pH ≤ 7.35

• Develop quickly over several minutes or hours

• It is fatal without prompt treatment

• is a progressive disorder of respiratory function caused by impaired pulmonary gas exchange

• In adults, is often caused by COPD

• develops over days to months and is shown by a raised PaCO2 with an elevated serum bicarbonate reflecting renal compensation

• Client can have acute exacerbation require emergency treatment

Causes & Clinical Manifestations:

1. Ventilation-perfusion mismatch

2. Impaired gas diffusion

3. Hypoventilation

Can lead to?

Causes & Clinical Manifestations:

1. Hypoventilation

Can lead to?

Causes & Clinical Manifestations:

Clinical Manifestations:

1. Dyspnea, tachypnea

2. Cyanosis

3. Restlessness, apprehension

4. Confusion, impaired judgement

5. Tachycardia, dysrhythmias

6. Hypertension

7. Metabolic acidosis

Causes & Clinical Manifestations:

Clinical Manifestations:

Clinical Manifestations:

1. Dyspnea -> respiratory depression

2. Headache

3. Papilledema

4. Tachycardia, hypertension

5. Drowsiness, coma

6. Systemic vasodilation, heart failure

7. Respiratory acidosis

Do we need to wear PPE while caring patient who receiving Endotracheal Intubation?

Contraindications For NIV Therapy:

1. Respiratory or cardiac arrest

2. Unable to fit mask

3. Facial trauma/burns/surgery

4. Recent upper airway or oesophageal surgery

5. Obstruction of the upper airway

6. Inability to protect airway or high risk in aspiration

7. Medically unstable: shock, arrhythmia, massive bleeding etc

8. Un-drained pneumothorax

Common Nursing Diagnoses for Respiratory Problems:

related to respiratory muscle fatigue

as evidenced by abnormal respiration rate and dyspnoea;

Common Nursing Diagnoses for Respiratory Problems:

related to presence of an artificial airway / retained secretions / excessive mucus production/ ineffective cough

as evidenced by abnormal breath sounds and decrease in pulse oximetry values; (presence of sputum)

Common Nursing Diagnoses for Respiratory Problems:

related to alveolar-capillary membrane changes / ventilation-perfusion imbalance

as evidenced by abnormal arterial bool gas values / decreased pulse oximetry values.

Barium Swallow, Pre-procedure care:

• NPO for (?) hours before the test

Abdominal Computed Tomography (CT), Nursing responsibilities:

• Stop metformin till (?) days after contrast CT to prevent possible complication of lactic acidosis

Complications:

1. Perforation - Signs of perforation: pain, bleeding, rapidly elevated temperature)

2. Bleeding from a biopsy site or scope trauma

3. Pulmonary aspiration of gastric contents

Post-procedure care:

• Immediately after the examination is competed, client is remained on left side until fully awake

• Monitor blood pressure, pulse, respirations and oxygen saturation according to hospital policy

• Keep client NPO until gag reflex returns

• Reassure mild bloating, belching or flatulence may occur

• Report if any difficulty in swallowing, epigastric pain, fever, vomiting blood or black tarry stool

Pre-procedure care

• Withhold medications:

- Iron supplement because iron residues produce an inky, black, sticky stool that interferes with visualization; stool can be viscous and difficult to clear

- Aspirin due to high bleeding risk

- Check and ensure diabetic patient withhold antidiabetic agents at the appropriate time and duration as instructed by healthcare professionals

- Sodium Phosphate (e.g. Fleet Phospho-Soda)

- Sodium Picosulphate + Magnesium Citrate (e.g. Picolax)

These two drugs are use in?

Indications

• Evaluate

- Jaundice

- Pancreatitis

- Persistent abdominal pain

- Pancreatic tumors

- Distal common duct stones

- Extrahepatic and intrahepatic biliary tract disease

- Strictures

Endoscopic Retrograde Cholangiopancreatography (ERCP) Contraindications:

1. Uncooperative client

2. Clients whose ampulla of Vater is not accessible endoscopically because of previous upper gastrointestinal surgery

3. Oesophageal diverticula

4. Known acute pancreatitis

Liver function test (LFT):

- An enzyme with high concentrations found in liver and relatively low concentrations found in heart, muscle and kidney

- Primarily used to diagnose liver disease

- When liver cells are damaged, ALT is released into the blood.

- More sensitive in detection of liver disease than in biliary obstruction

- Differentiates between haemolytic and hepatic jaundice

Liver function test (LFT):

- An enzyme present in tissues of high metabolic activity

- It is released into the circulation following the injury or death of cells

- Any disease that causes change in these highly metabolic tissues will result in a rise in AST levels

- Following several cell damage, serum AST level will rise in 12 hours and remain elevated for about 5 days

Liver function test (LFT):

- An enzyme originating mainly in bone, liver, placenta, with some activity in the kidney and intestines

- It is use as an index of liver and bone disease

- In liver disease, the blood level rises when excretion of this enzyme is impaired as a result of obstruction in the biliary tract

Liver function test (LFT):

- Present mainly in liver, kidney and pancreas

- Use to determine liver cell dysfunction and to detect alcohol-induced liver disease

- is elevated in all forms of liver disease

- It is much more sensitive than ALT/ALP/AST in detecting obstructive jaundice, cholangitis and cholecystitis

Liver function test (LFT):

- Result from the breakdown of haemoglobin in RBC

- It is removed from the body by the liver, which excretes it into bile

- Bilirubin gives bile its major pigmentation

- A rise in serum bilirubin level occurs when there is excessive destruction of RBC or when the liver is unable to excrete the normal amounts of bilirubin produced

Airborne Precautions:

Patient known or suspected to be infected with microorganism transmitted by airborne droplet nuclei < (?) microns (μm)

Droplet Precautions:

• Bed spacing > (?) meter

When to perform hand hygiene?

1. Before patient contact

2. Before clean and aseptic procedure

3. After body fluid exposure risk

4. After touching a patient

5. After touching patient surroundings

How to perform hand hygiene effectively?

1. Bare below elbow

2. Remove all accessories over hands

3. Keep fingernail short (~0.5cm)

4. No artificial nails / nail polish

5. Roll up sleeves

Handling of body substances:

Mop the area extensively of at least 1-meter from contamination with appropriate disinfectant e.g. sodium hypochlorite solution (?).

Handling of body substances:

Mop the area with sodium hypochlorite solution (?) and leave for 10 minutes.

Risk factors of Chronic Respiratory disease:

1. tobacco smoking

2. second hand tobacco smoke

3. outdoor air pollutants

4. other indoor air pollutants

5. allergens

6. occupational agents

Risk factors of Chronic Respiratory disease:

1. diet and nutrition

2. post infectious chronic respiratory diseases

Baseline evaluation:

• -MMRC,

• Borg dyspnea scale, visual analogue scale (VAS),

• COPD Assessment Test (CAT)

• ACT Asthma Control Test (ACT)

Baseline evaluation:

• Directly observed /self-reported +Spirometry, ABG /Oximetry

Baseline evaluation:

• 6 minutes walking test

• Cardiopulmonary exs testing (CPET)

Baseline evaluation:

• Health related Quality of Life (HRQL)

• Chronic respiratory disease questionnaire(CRDQ) & St George Respiratory Questionnaire Score (SGRQS)

• SF36

Baseline evaluation:

• BMI/ BW

ABG:

normal range of PaCO2

ABG:

normal range of HCO3

Structure of the Respiratory System:

• Mouth

• Nose

• Pharynx

• Larynx

• Upper trachea

Structure of the Respiratory System:

• Trachea

• Lungs

• Bronchi & Bronchioles

• Pulmonary capillary network

• Diaphragm

Mode of transmission:

• bacteria grow well in warm water (20 to 45°C)

• Can be found in aqueous environments such as water tanks, hot and cold water systems, cooling towers, whirlpool spas, water fountains, humidifiers and home apparatus that support breathing

• People get infected when breathe in contaminated droplets (aerosols) and mist generated by artificial water systems, when handle garden soils, compost and potting mixes.

• Not transmitted by person-to-person contact, eating or drinking

Clinical Manifestation:

In severe cases, neurological symptoms (e.g. confusion) and respiratory failure may appear and some may cause death.

Preventive Measures:

• Operate and maintain properly designed man-made water systems

• Maintain good personal hygiene.

• Build up good body immunity

• Inspect, descale and disinfect strainers in water taps and shower heads regularly

• Avoid using domestic water filters as clogging occurs easily, and promote growth of microorganisms

• If water filters are used, the pore size should be 0.2 micrometer (μm) and change the filter periodically

Cough Suppressants / Antitussives:

• Pholcodine

• Phensedyl

Cough Suppressants / Antitussives:

• Benadryl

Nursing care for clients:

• Clients with COPD who have problems with breathing are not usually given this med. Presence of COPD may influence client’s response to opioid

• Monitor clients (especially of older adults) to check respiratory rate frequently because respiratory depression is possible due to the suppression of central nervous system.

• Monitor clients for nausea and constipation because these are the most common side effects. Overuse may cause severe constipation

• Educate clients that physical addiction is rare, but possible, for opioid antitussive

• Instruct clients to notify the healthcare provider if symptoms have not improved within a few days or have worsened because these may indicate more serious respiratory problems

Nursing Care for Clients:

• Educate client not to drink alcohol and avoid concurrent use of other CNS depressants (e.g. opioids, sedative-hypnotics, barbiturates, or antidepressants) because CNS depression can occur

• Change position slowing when getting up from lying or sitting position because occasionally cause light-headedness, dizziness, or fainting when you get up quickly

• Remind client not to drive or perform other hazardous activity if drowsiness occurs

• Educate client that should be used only for short periods. Short therapy decreases the risk for rebound symptoms from prolonged use or the possibility of abuse.

• loosen bronchial secretions so that they can be eliminated by coughing

• Used for reducing the thickness or viscosity of bronchial secretions

• Increasing mucus flow that can be removed more easily by coughing

Nursing Care for Clients:

• Assess the type, frequency, character of cough, including sputum so as to get the baseline data for comparison in the future and evaluate of therapeutic response

• Assess rate, rhythm of respirations, increased dyspnea; sputum for detection of the side effect of bronchospasm; discontinue if it occurs

• Encourage client to have deep breathing and coughing exercise to facilitate removal of secretions from the airway

• Have a suction machine at the bedside particularly for elderly or debilitated clients who might require suctioning for removal of the sputum

• Teach client to drink more fluid each day if not contraindicated to help thin secretions to help get the mucus out.

• Educate the client the purpose of mucolytics is to make the sputum more liquid and easier to spit out when you cough. The mucolytics drug alone will not make your stop coughing.

Tuberculin Skin Test (Mantoux Method):

• (?) ml of Tubercle bacillus extract (tuberculin) purified protein derivative (PPD) is injected to intradermal layer in tuberculin syringe with 26- 27 gauge needle

Tuberculin Skin Test (Mantoux Method):

• The test is read (?) hours after injection (peak reaction period)

Tuberculin Skin Test (Mantoux Method):

• An induration (not erythema) of > (?)mm : positive reaction

Isolation room for air-borne precaution:

1. With negative pressure

2. At least 6 – 12 air exchange per hour

3. Air should not be re-circulated and exhausted to the outside

4. Keep door open