LOWER RESPIRATORY PROBLEMS

Acute BronchitisPneumoniaTuberculosisCopyright 2/4/2013Michelle Gardner

ACUTE BRONCHITIS Inflammation of the

bronchi in the lower respiratory tract.

Usually occurs with upper respiratory

tract infection

ACUTE BRONCHITIS

EtiologyMay be viral /bacterial infectionAt risk -- those with impaired immune

defenses/cigarette smokingMarked seasonal incidences

ACUTE BRONCHITISClinical ManifestationsPersistent cough Mildly elevated T, RR, HRBreath sounds

Diagnostic AssessmentHistory/PhysicalCXR – differentiate acute bronchitis/pneumonia

ACUTE BRONCHITISCollaborative Management Treatment is generally supportivea. Fluidsb. Rest c. Anti-inflammatory agentsd. Other Antibiotics

Antitussives Bronchodilators

PNEUMONIA Leading cause of death from an infectious

disease Excess fluid in the lungs resulting in an

inflammatory process Caused by various microbial agenta. Bacterial b. Viral c. Fungal

Incidence/Prevalence US – 4 million cases of pneumonia 8th leading cause of death Highest incidence in older adults and people with

debilitating illness1. Nursing home residents2. Those mechanically vented

PNEUMONIA

PNEUMONIA

PNEUMONIARISK FACTORS1. Older Adult2. Bed rest/prolonged immobility3. Debilitating illness4. Human immunodeficiency virus (HIV)5. Intestinal / gastric feedings 6. Malnutrition

PNEUMONIA

CLASSIFICATION1. Community –Acquired Pneumonia (CAP)2. Hospital –Acquired Pneumonia (HAP)3. Aspiration Pneumonia4. Opportunistic Pneumonia

COMMUNITY-ACQUIRED PNEUMONIA

1. Onset occurs in the community /first 2 days of hospitalization

2. Incidence 3. Smoking, alcoholism, immunosuppressive disease4. Age > 65 years, multiple medical co-morbidities5. Causative organism identified only 50% of the time

HOSPITAL ACQUIRED PNEUMONIA

1. Occurs 48 hrs. or longer after admission2. Bacteria are responsible for the majority of

HAP – Pseudomonas, Staph. Aureus 3. Some causes:a. contaminated respiratory therapy equip. b. endotracheal intubation (VAP) c. general debility

HOSPITAL ACQUIRED PNEUMONIA

• Ventilator –Associated Pneumonia• Nosocomial pneumonia• Associated with endotracheal intubation

/mechanical ventilation• Bacterial Pneumonia• Ventilator Bundle

HOSPITAL ACQUIRED PNEUMONIA

• Methicillin-Resistant Staphylococcus Aureus (MRSA)Specific strains of Staphylococcus are resistant

to all available antibiotics except VancomycinHighly virulent

ASPIRATION PNEUMONIA

1. Aspiration of material from the mouth/stomach into the trachea/lungs

2. Typically occurs in clients with altered consciousness and impaired gag reflex

3. Another risk factor – tube feedings4. Prevention –

OPPORTUNISTIC PNEUMONIA Occurs in client’s with altered immune

response. Highly susceptible to respiratory infections Pneumocystis jiroveca (carinii) – fungal

opportunistic pathogen Affects about 70% of HIV virus infected

individuals Common opportunistic infection

OPPORTUNISTIC PNEUMONIA

At risk: 1. those with immune deficiencies2. severe protein calorie malnutrition3. clients who have received organ transplants4. clients treated with chemotherapy, radiation

therapy

OPPORTUNISTIC PNEUMONIA

Clinical ManifestationsInsidious Tachycardia Fever Non-productive coughTachypnea Dyspnea

TreatmentBactrim – primary agent

BACTERIAL PNEUMONIA

Clinical Manifestations1. Fever 2. Shaking chills3. Productive cough 4. Pleuritic chest pain 5. Crackles on auscultation6. Altered mental status

VIRAL PNEUMONIA

Clinical Manifestations1. Fever2. Dry non-productive cough3. Chills4. Malaise

DIAGNOSTIC STUDIES1. History/physical2. Chest x-ray3. Sputum gram stain, C&S (should be

collected before antibiotic therapy started)

4. CBC 5. Serum electrolyte

PNEUMONIA

Empiric Therapy

Treatment is based on observation and experience without always knowing the exact cause.

BACTERIAL PNEUMONIA

COLLABORATIVE CARE1. Antibiotic therapy –Macrolides recommended a. Zithromax (azithromycin) b. Biaxin (clarithromycin)2. Oxygen therapy 3. Analgesics 4. Antipyretics5. Rest/restrict client’s activity

VIRAL PNEUMONIA

No definitive treatmentAntiviral agentsa. Symmetrel (amantadine)b. Flumadine (rimantadine)

VACCINEInfluenza vaccineo Mainstay of preventiono Recommended annually for clients Pneumoccal Vaccineo Good for a lifetimeo 65yrs and older

COMPLICATIONS

o Usually runs an uncomplicated course.o Complications may include a. pleural effusion b. confusion

NURSING MANAGEMENTa. Assess respiratory statusb. Oxygen therapy – as per MD orderc. Maintain patent airwayd. High-calorie, high –protein foodse. Hydrate f. Administer medications as orderedg. Document findings

PULMONARYTUBERCULOSIS

TUBERCULOSIS

o Bacterial infection o Caused by Mycobacterium tuberculosiso Communicable diseaseo Primarily affects the lungso Can affect other organs & body structureso Transmitted through airborne dropletso The disease may be an active process or it may

remain dormant

RISK FACTORS* Persons in constant, frequent contact with

untreated/undiagnosed individuals* Abuse IV drugs or alcohol* Homeless persons, residents of inner-city

neighborhoods* Foreign-born immigrants from countries with high

prevalence* Those living in crowded areas -- mental health

facilities, long-term care facilities * Those with immune dysfunction or HIV

PATHOPHYSIOLOGY

a. M. tuberculosis, a gram-positive, acid-fast-bacillus, & a slow-growing organism

b. Transmitted via airborne dropletsc. Bacilli are inhaled & deposit themselves on the

bronchioles/alveolid. Here they may be killed by the host's immune

system, or lie dormant without causing symptoms, or produce primary TB

e. It’s possible for the bacilli to proliferate after a period of dormancy, causing reactivation of TB.

TUBERCULOSIS

Contraction of TB typically requires close, repeated contact over a long period of time

CLINICAL MANIFESTATIONS

Early stages the client may be symptom free• Active disease: 1. Fatigue2. Low-grade fever / night sweats3. Anorexia / weight loss4. Persistent cough 5. Chest tightness, & dull, aching chest pain may

accompany the cough

TUBERCULIN SKIN TESTING

Mantoux test - PPD (purified protein derivative)* Gold standard for screening * Most reliable determinant of TB infection* Skin test should be read 48-72 hrs. after PPD

administration* A positive test is determined by the size of the area

of induration (hardened & raised area)

MANTOUX TEST

MANTOUX TEST (cont’d)* A positive reaction indicates the presence of a

tuberculosis infection* Does not show whether the infection is inactive

(dormant) disease or active.* Immunosuppressed clients or those with HIV-

infection with a induration reaction 5mm or greater are considered positive

TUBERCULOSIS* An area of induration

measuring 10mm or more in diameter, 48-72 hours after injection, indicates the individual has been exposed to TB

QuantiFERON-TB Gold

New test for detection of TBTest is an enzyme-linked immunosorbent

assay (ELISA)Detects the release of interferon-gamma by

WBC’S when the blood of a pt. with TB is incubated.

Results of the test are available in less than 24 hr.

DIAGNOSTIC ASSESSMENT

Chest x-ray Sputum cultures –most accurate means of

making a diagnosis.a. (3) consecutive sputum specimens on three

different days are obtained for C&S b. A positive sputum culture of tubercle bacilli

confirms the diagnosis

VACCINE

Immunization with bacille Calmette-Guerin (BCG) is still given to prevent TB in many parts of the world.

Given to children in high prevalence areas in developing countries

BCG vaccination can result in a positive reaction on TST

COLLABORATIVE CARE

Most client's are treated on an outpatient basis1. Hospitalization used for – severely ill,

debilited, & those who experience adverse drug reactions

2. Mainstay of TB treatment – Drug Therapy

TUBERCULOSIS

What is multidrug – resistant TB?

Resistance develops to at least two or more anti-TB drugs

Standard therapy has been revised

TUBERCULOSIS

Treatment consist of a combination of at least 4 drugs

Reason for the combination therapy a. Increase therapeutic effectiveness b. Decrease the development of resistant strains of M. tuberculosis

TUBERCULOSIS

FIRST LINE DRUGS1. Isoniazid (INH)2. Rifampin (Rifadin)3. Ethambutol

(Myambutol)4. Streptomycin5. Pyrazinamide

DRUG THERAPY

* Length of time medication must be taken 6/12 months

* Strict adherence to the drug regimen is crucial to suppress the disease

* Non-compliance is a major factor in the emergence of MDR - TB

DRUG THERAPY

Isoniazid- (INH)First drug of choice for TB prophylaxisAdverse effects Administer pyridoxine (vitamin B6) Hepatitis – hepatotoxic

DRUG THERAPY

Rifampin (Rifadin)Used in combination with INH and other antitubercular medsCan cause hepatitis, flu-like symptoms Causes body fluids – turn red/orange.Monitor liver function studies, renal studies for evidence of toxicity

DRUG THERAPY

Pyrazinamide (Tebrazid)Used with INH and RifampinToxic to the liver Monitor liver function

DRUG THERAPY

Ethambutol (Myambutol)Toxic effect Early signs Baseline visual exam prior to therapySchedule periodic eye exams

DRUG THERAPY

StreptomycinAminoglycoside antibiotic2 drawbacks *must be given parenterally * has toxic effect on the kidneysMonitor u/o, weight, renal function studies Ototoxicity

NURSING INTERVENTIONS

1. Hospitalization2. Respirator masks used when entering the client’s

room3. Instruct client to cough into tissues & wear a mask

when leaving the hospital room4. Monitor the client’s respiratory status, breath

sounds, O2 saturation & document

NURSING INTERVENTIONS

5. Administer medications as ordered by MD 6. Encourage high-protein & high CHO foods7. Monitor laboratory results periodically -- (liver

function test)8. Educate the client about strict compliance with

medications9. Inform client about adverse effects of medications10. Encourage close follow-up

THE ENDPLEASE REVIEW

& STUDY