Respiratory Disorders

Review of Anatomy and Physiology

-upper airway: nose, mouth, laryngopharynx, larynx
:nose acts as a filter when you breathe things in
:larynx is where inhaled air is warmed and humidified; has voice box where sound is produced
:is at the top of the trachea (the transition point between the upper and lower airways)
-epiglottis is tissue that closes over the larynx when you swallow (is examined with swallow test)
-lower airway: trachea, bronchi, bronchioles, alveoli
:start at the trachea, where it divides into the right and left main stem bronchi
:bronchi branch to the primary, secondary, and tertiary bronchi
:then branch down into the bronchioles and then finally the alveoli
:the alveoli is where gas exchange occurs (healthy adult has about 3 million alveoli)
-trachea: connects to the lung
-trachea and bronchi
:lined with ciliated epithelium that sweeps mucous and foreign matter to the posterior pharynx
where it is swallowed
:smokers are more prone to bronchitis because they kill the cilia off and do not get the same mobility
of the mucous, which makes it harder to cough things up
:dust and debris are trapped by the action of the goblet cells
-right lung
:has three lobes which are separated by fissures and divided into 10 sections
-left lung
:has two lobes which are divided into 8 segments
-alveoli
:where gas transport occurs
-thorax
:ribs hinge on the spine
:this is where the pleural space is
:the pleural space is air-tight and has negative atmospheric pressure
:ideally you want negative to atmospheric pressure
:when you get positive intrathoracic pressure, you have lung collapse
:you will need a chest tube to reestablish the negative pressure
:if the patient is intubated, you want to make sure of placement because the right lung is wider, shorter,
and a little bit more vertical than the left lung
:make sure the placement is right and they did not go into the bronchus
:another way to check is to hook the ambubag up (both sides of the chest should rise)
-inspiration
:the ribs move up and out
:the chest volume increases
:the diaphragm contracts (shortens and flattens to increase chest volume)
:air come in and lungs enlarge
-expiration
:the lungs become smaller
:the ribs are pulled down
:the diaphragm comes up and air is forced out
:with COPD they loose elasticity and recoil, which causes air trapping (causes barrel chest appearance)

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Respiratory Terms
-hypoxemia
:low levels of oxygen in the blood
-hypoxia
:decreased tissue oxygenation
:signs and symptoms include restlessness, confusion, increased pulse, increased respirations, cyanosis,
digital clubbing, and decreased O2 sat on pulse oximeter
:with neuro assessment assess how well they pay attention to things, are they disoriented, are they confused
:these can be early warnings that they are not getting enough oxygen
:usually have confusion first, then an altered level of consciousness
:sometimes they will get hostile (this is a definite warning sign that something is going on)
:with pulse ox, the lower the oxygen, the less accurate the reading (at ≤70% an ABG would be done)
-hypercapnia
:not enough CO2 is eliminated by the lungs so blood CO2 level increases
:as CO2 increases, you get respiratory acidosis (this can happen with COPD)
:this increase in CO2 causes vasodilation
:signs and symptoms include headache, confusion, coma, bounding pulse, and warm/sweaty extremities
-hypercarbia
:increased partial pressure of arterial carbon dioxide (PaO2)
:results in “hypoxic drive”
-pneumothorax
:occurs with the accumulation of too much atmospheric air in the pleural space
:you go from negative pressure to positive pressure, which results in the lung collapsing
:it results in a rise in intrathoracic pressure
:signs and symptoms include chest pain, dyspnea, apprehension, cyanosis, decreased breath sounds on
the affected side, and abnormal chest x-ray readings
:chest tubes may be indicated to allow the air to escape and the lung segment to reinflate
-hemothorax
:when blood enters the pleural cavity (usually occurs after blunt chest trauma or penetrating injuries)
:bleeding caused by injuries to the lung parenchyma
:ex: pulmonary contusions or lacerations, which are often associated with rib and sternal fractures
:signs and symptoms are similar to pneumothrorax
:usually see dyspnea (shortness of breath) first and then tachycardia
:with pulse ox- don’t just look at oxygen saturation, but look at pulse also
:the more tachycardia they get, you know something is going on because the body is compensating
:the heart starts pumping faster to try and get more oxygen to the body
-atelectasis
:collapse of the affected alveoli and associated lobes of the lungs
:usually seen in the bases of the lungs
:prevents the exchange of oxygen and carbon dioxide
*this can be prevented by using the incentive spirometer (ideally at least 10 times/hour when awake)
:also encourage them to turn, cough, deep breathe, and get out of bed as much as possible
:the more activity they do and the more they use the incentive spirometer, the more oxygen they are
getting and keeping the alveoli open, which helps prevent the alveoli from collapsing
:when this happens, the patient ends up on a ventilator, and it can be life threatening
-pleural effusion
:collection of fluid in the pleural space
:this can be a problem for patients with lung cancer (may have thoracentisis done to get excess fluid out)
:the accumulation of fluid increases dyspnea, discomfort, and risk for infection (due to fluid sitting there)
:the goal of treatment is to remove pleural fluid and prevent its reaccumulation
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Important Signs and Symptoms
-cough
:ask how long (days, weeks, months)
:days could indicate a common cold
:weeks could indicate walking pneumonia or bronchitis
:months could indicate tuberculosis or something serious
:does it occur at specific times of the day or with physical activity
:coughing early in the morning and/or at night could indicate asthma
:in spring, pollen is high early in the morning and goes back up at night
:when cough occurs with physical activity, it could be a respiratory or cardiac problem
:with congestive heart failure, they get a cough with activity as well
:is it productive or nonproductive, congested, dry, or hacking
:greenish or yellowish (bacterial or viral), blue green (pseudomonas), blood (tuberculosis)
:congestion nasally as well as in the chest could indicate upper respiratory infection
:congestion just in the lungs could indicate bronchitis
:dry hacking cough (smokers cough) can be seen in early signs of COPD
-sputum production
:note the duration, color, consistency, odor, and amount
:is it a little bit or are you using 10 tissues
:ask how many tissues they are using a day, how many times a day are they coughing something up
:pus may be seen with infection or lung cancer with really bad effusion
:normally the tracheobronchial tree can produce up to 90ml of sputum a day (equivalent of 3 medicine cups)
-chest pain
:can be due to pleural, musculoskeletal, cardiac, and gastrointestinal causes
:musculoskeletal- in car accident, could have costrochondritis (inflammation over the chest wall)
:gastrointestinal- with GERD, the incompetent lower esophageal sphincter causes acid to back up
:especially with infants and children, GERD can actually cause an asthma attack
:coughing, deep breathing, or swallowing usually worsens chest wall pain
:does a coughing fit make it worse (continual coughing can cause chest pain itself)
:does deep breathing make it worse or better
:does swallowing make is worse (is indicative of chest wall pain)
-dyspnea (shortness of breath)
:can be due to respiratory or cardiac problem
:determine the type of onset (slow or abrupt)
:does it come on with their first step or after climbing two flights of stairs
:duration (# of hours, time of day)
:how long does it take to recover from the shortness of breath, and what were they doing
:relieving factors (changes of position, medication use, activity cessation)
:evidence of audible sounds (wheezing, crackles, stridor, or diminished/absent breath sounds)
:is wheezing inspiratory or expiratory or both
:with diminished or absent breath sounds (has lung collapsed, do they have pneumonia)
:if diminished/absent breath sound or crackles in just one lobe, then bacterial pneumonia (left shift)
:if diminished/absent breath sound or crackles in both lobes, then viral pneumonia (high lymphocytes)
:ask the patient if the dyspnea is interfering with their activities of daily living
:if yes, then how severely? Scale of 1-4 (1 is mild, 4 is barely functioning with ADL’s)
:paroxysmal nocturnal dyspnea (is associated with COPD and CHF)
:intermittent dyspnea during sleep
:orthopnea (is associated with COPD and CHF)
:shortness of breath that occurs when lying down but is relieved by sitting up
:assess by how many pillows they have to use (ex: 2 pillow orthopnea, 3 pillow orthopnea, etc.)
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Diagnostic Tests
-pulse oximetry
:ideally want values between 95-100%
:they may be a little lower in an older patient due to poor circulation
:may be a little lower in patients with darker skin
:with saturation below 91% you want to implement treatments
:with COPD, do not use 4L of O2 because you would wreck their hypoxic drive (they could stop breathing)
:pulse ox below 85% means that a lot of tissues in the body are not getting oxygen (is a serious concern)
:pulse ox values below 80% can become life threatening
:when it is at 80% and definitely below 70% they will do ABG’s to determine what is going on
-chest x-ray
:can detect pathologic lung changes (ex: pneumonia, TB, atelectasis, pneumothorax, tumor, or pleural fluid)
:also used to evaluate placement of chest tubes and endotracheal tubes
:with chest tubes an x-ray lets them see if the lung is re-expanding
:serial chest x-rays (at least one a day) with chest tubes to track the progression
:when they take out the chest tube they will do an x-ray to verify that the lung is re-expanding
:sometimes when the chest tube is taken out the lung will collapse and they have to put another one in
:with endotracheal tubes they are checking to make sure it has not gone into the bronchi
*the tube should be on the right
:notify technician if your patient is pregnant
-bronchography
:radiopaque dye covers the bronchial mucosa
:this helps visualize what is going on
:make sure the patient is not allergic to iodine or shellfish
-angiography
:IV radiopaque dye
:used to visualize the pulmonary vessels (helps see problems with circulation in the lungs)
:make sure the patient is not allergic to iodine or shellfish
-lung scan
:inject technetium IV (a nuclear tracer dose)
:allows a better image of the lungs
:done if lung cancer or a mass is suspected
-ventilation perfusion scan (V2 scan)
:done when they are not sure if it is a ventilation problem or a perfusion problem
:lung perfusion scan
:visualize clots and checks if there is adequate circulation to carry oxygen to the cells
:lung ventilation scan
:inhale xenon gas (a nuclear tracer dose)
:visualize if oxygen gets to competent alveoli (checks if alveoli are expanding properly)

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*Bronchoscopy
-a flexible scope is inserted to visualize airways
-sputum studies and biopsy can be done
-informed consent is required
-patients need to be NPO for 8-12 hours before procedure
-the patient should have IV access
-the patient is awake during the procedure
:may receive IV Demerol and Versed/Valium for conscious sedation
:Versed has an amnesic property so the patient does not remember the procedure
:also use conscious sedation for an EGD
-post procedure
:patient is NPO until gag reflex returns
:have them lye on their side or head elevated at least 30o until the gag reflex returns
:don’t give them anything to eat or drink, including medications until gag reflex returns
:vital signs checked frequently
:auscultate breath sounds (do not want to hear any crackles)
:any sputum expectorated should be observed
:look for blood to make sure there were no perforations during the exam

Biopsy
-tissue sample for analysis of cell structure
-obtained by bronchoscopy, thoracentesis, guided needle biopsy (done by CT scan), or thorocotomy surgery
:thorocotomy is when the chest wall is cracked and they take out what they need
-will be done if lung cancer is suspected

*Thoracentesis
-sterile needle or catheter inserted into the pleural space where tissue and fluid are withdrawn
-informed consent is required
-a local anesthetic is injected into the skin of the thorax (to help numb the area)
-positioning
:can be sitting on the edge of the bed with arms and head on a bedside table
:or lying on unaffected side with head of bed elevated 30-45o
-post procedure care
:if the pleura fails to seal after the needle is withdrawn the lung may collapse (pneumothorax)
:pneumothorax is when air gets into the cavity
:breath sounds should be frequently checked to see if they are diminished or absent
:this could indicate a pneumothorax
:the puncture site should be clean and dry
:drainage from the site indicates the pleura did not seal properly
:immediately notify the physician if this occurs

Sputum Specimen
-obtained by either nurse or a respiratory therapist
-sputum is cultured for bacteria, viruses, and fungi
-the sample is gram stained to show gram positive and gram negative organisms (this show bacterial infection)
-tuberculosis is an example of a bacilli that does not stain positive or negative (it is an acid fast bacilli)

Sputum Cytology
-cell studies that identify malignancy in cell structure (think of lung cancer)

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Oxygen Therapy
-think of oxygen as a drug (too much or not enough can be bad)
-monitor if the therapy is making them better, worse, or no change at all
:if they are asthmatic, it does not matter how much you give them because nothing will get in
:they would need a bronchodilator or solumedrol to get the bronchioles opened up
-the oxygen content of atmospheric air is about 21%
-the goal of O2 therapy is to use the lowest fraction of inspired oxygen (FIO2) to obtain the most acceptable
oxygenation without causing the development of harmful side effects
-when patients are on oxygen, they will be monitored with a pulse oximeter (for pulse and oxygenation)
-ABG analysis is the best measure for determining the need for O2 therapy and for evaluating its effects
:this is the gold standard for measurement

**at least one ABG problem on the test

Acid Base Disturbance pH pCO2 HCO3

Normal Values 7.35-7.45 35-45 24-26
Respiratory Acidosis Down Up Normal
Respiratory Alkalosis Up Down Normal
Metabolic Acidosis Down Normal Down
Metabolic Alkalosis Up Normal Up

Values pH pCO2 HCO3

Respiratory Acidosis 7.30 47 24
Metabolic Alkalosis 7.60 40 28
Respiratory Alkalosis 7.50 32 25
Metabolic Acidosis 7.20 37 20

Respiratory Acidosis
-asyphxia or suffocation
-hypoventilation (due to pulmonary, cardiac, musculoskeletal, or neuromuscular disease)
-central nervous system depression (due to drugs such as opioids/morphine or head injury)

Respiratory Alkalosis
-from blowing off too much CO2
-increased respirations (from anxiety, pain, exercising too hard)
-respiratory stimulation (due to drugs, respiratory disease, fever, hypoxia, high room temperature)
-gram negative bacteremia (a septic patient is likely to have respiratory alkalosis)

Metabolic Acidosis
-renal disease (kidneys can not excrete acids or they do not produce enough bicarb)
-excess production of acid
:due to hepatic disorders (liver failure, advanced cirrhosis)
:endocrine disorders (thyroid problems), shock, or drug intoxication
-decreased HCO3 (due to renal failure and diarrhea)

Metabolic Alkalosis
-loss of HCl acid (due to vomiting or gastric suction)
-excess ingestion of alkaline substances (taking too many Tums)
-loss of potassium (due to increased renal excretion caused by diuretics {Lasix} and steroids)

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Hazards/Complications of O2 Therapy
-combustion (no smoking, make sure electrical equipment is grounded with three prongs, no fray cords)
-oxygen induced hypoventilation (refers to the hypoxic drive especially with COPD patients)
-oxygen toxicity (if O2 concentration is more than 50% for 24-48 hours)
:prolonged exposure can cause damage to the lungs resulting in edema and pulmonary hemorrhage
:room air is 21% oxygen and 79% nitrogen (this helps prevent the alveoli from collapsing)
:if they are not getting the same amount of nitrogen, you have to worry about the collapse of alveoli
-absorption atelectasis
:this happens when they get atelectasis (collapsed alveoli)
:you will hear a lot of crackles and decreased/absent breath sounds
:this is a result of oxygen toxicity
-drying of the mucous membranes (especially with the nasal cannula)
:may need to use humidified oxygen
:with a trach, they may have a trach collar on (to help keep membranes moist)
-infection (change equipment based on hospital policy)
:with humidification you have to watch for infection (from something growing in the equipment)
-when they get off the oxygen, assess breath sounds to make sure they don’t have any respiratory distress

Oxygen Delivery Systems

*Nasal Cannula
*nasal cannula can supply up to 44% oxygen
-percentage of oxygen goes up in increments of 4%
*24-44% FIO2 @ 1-6 L/min
-24% @ 1 L/min
-28% @ 2 L/min
-32% @ 3 L/min
-36% @ 4 L/min
-40% @ 5 L/min
*44% @ 6 L/min
-flow rates greater than 6 L/min do not significantly increase oxygenation because of the anatomic dead space
:anatomic dead space refers to the air in the nose, mouth, larynx, pharynx, trachea, and bronchial tree
:the air gets trapped there and does not reach the alveoli, therefore you don’t get the gas exchange
:the reason for the space is to warm very cold inhaled air and to act as a filter
-effective O2 concentration can be delivered to both mouth and nose breathers
**the patient who retains CO2 rarely receives O2 at a rate higher than 2-3 L/min because of the concern for
losing the drive to breathe, increasing the risk for apnea or respiratory arrest
-advantages
:lightweight, comfortable, inexpensive, can be used continuously (while moving around, eating, etc.)
:can be used with meals and activities
-disadvantages
:nasal mucosal drying (if not on humidified air)
:can cause skin irritation around the nares and behind the ears (can use foam or gauze to help with irritation)
:variable FIO2 (make sure they are getting as much oxygen as they need)

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*Simple Face Mask
*flow rate must be set at least 5 L/min to flush mask of CO2
-40% to 60% FIO2 @ 5-8 L/min
-40% @ 5 L/min
-45-50% @ 6 L/min
-55-60% @ 8 L/min
-this is used for short term oxygen therapy or in an emergency situation
-the nurse needs to ensure that the mask fits properly so that the inspired oxygen concentration is maintained
-advantages
:simple to use, inexpensive
-disadvantages
:poor-fitting, variable FIO2, must take off mask to eat
:if person is severely compromised and cant take the mask off to eat, you may want to use a nasal cannula

*Partial Rebreather Mask

*you need a flow rate of O2 high enough to keep the reservoir bag 2/3 full during inspiration and expiration
:if it is not 2/3 full you will not get an accurate FIO2 concentration
-60-75% FIO2 @ 6-11 L/min
-it is important that the bag remains slightly inflated at the end of inspiration
:otherwise, the patient will not be getting the appropriate amount of oxygen
-make sure the reservoir does not twist or kink (this can cause the bag to become deflated)
-advantages
:moderate oxygen concentration
-disadvantages
:can get warm, poorly fitting, must remove to eat
:may not be able to tolerate if claustrophobic, consider using a nasal cannula if this is the case

*Non Rebreather Mask

-this is the last step before you go on a ventilator
-can deliver an FIO2 greater than 90%
-must have enough oxygen flow to maintain the reservoir bag at least 2/3 full
-used most often in patients with deteriorating respiratory status who may soon need to be intubated
-this mask has a one-way valve between the mask and the reservoir and two flaps over the exhalation ports
:the flaps prevent room air form entering the mask (because room air has a FIO2 of 21%)
-advantages
:get a high oxygen concentration
-disadvantages
:can be poorly fitting, traumatic for a closterphobic patient

*Venturi Mask
-24-55% FIO2 with flow rates as suggested by the manufacturer (usually 4-10%)
-delivers the most accurate oxygen concentration
-has a mechanism that pulls in a specific proportional amount of room air for each liter flow of O2
:has a dial on it to set the FIO2 to the desired level
-is the best O2 delivery form for patients with chronic lung disease since it delivers a precise O2 concentration
-people tend to tolerate this one better because it does not have a reservoir bag attached to it
-advantages
:provides low levels of supplemental oxygen, precise FIO2, additional humidity is available
-disadvantages
:must remove to eat, may get claustrophobic
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Cancer of the Larynx
*a very aggressive form of cancer
-untreated patients usually die within 2 years
-there are 43,000 newly diagnosed cases of oral and laryngeal cancers per year
-three times more males than females are affected, and most cases occur in people over 60 years of age
*risk factors
:the two most important risk factors are smoking and alcohol use
:the risk factor is doubled when smoking and alcohol are used together
:other factors- chewing tobacco, pipe smoking, marijuana, voice abuse, chronic laryngitis,
exposure to industrial chemicals or hardwood dust, and complete neglect of oral care
-history
:the patient may have trouble talking due to hoarseness, shortness of breath, tumor, and/or pain
:a lot of times they end up with a Gtube and trach because of the tumor
:usually they have a lot of pain and will be given Lortab
:if the patient is a smoker, calculate how many pack-years
:the number of packs smoked per day times the number of years the patient has smoked
:the higher it is, the higher the risk factor
:second hand smoke has been shown to be as equally damaging
:if the patient drinks alcohol, ask how many and what type drinks per day and for how many years
:street drugs can affect their pain tolerance and the way they respond to pain medications
:ask about exposure to any environmental or occupational pollutants
:assess dietary habits and any weight loss (may not be able to eat solid foods because of pain in their neck)
:determine if the patient has chronic lung disease (many will also have COPD also from smoking)
*clinical manifestations (be able to distinguish between early, late, and very late signs)
:hoarseness, change in voice quality (early)
:lump in the throat for 3-4 weeks or longer (early)
:burning sensation when drinking citrus juices or hot liquids (early)
:pain
:persistent or recurrent sore throat (late)
:difficulty swallowing (late)
:foul breath (late)
:shortness of breath (late)
:anorexia and weight loss (very late)
:persistent, unilateral ear pain (very late)
-diagnostic evaluation procedures
:laboratory test: CBC, bleeding times, urinalysis, SMA-20 (looks at everything)
:decreased protein and albumin levels often seen with alcoholism
:renal and liver function tests
:done to rule out metastatic disease
:done to evaluate patients ability to metabolize medications and chemotherapeutic agents
:GGT will be elevated with bulimic or alcoholic; SGOT and SGTP look at overall function of the liver
:x-rays- views of the skull, sinuses, neck, and chest
:are useful to diagnose metastases, second primary tumors, and tumor invasion
:CT of head and neck- helps to evaluate the tumor’s exact location (will be done for radiation therapy)
:MRI- can differentiate normal from diseased tissue
:more sensitive than a CT in defining the extent of soft-tissue invasion
-medical management
:assess respiratory rate, breath sounds, pulse oximetry, ABG’s, and pulmonary function tests
:treatments may include surgery, radiation, and/or chemotherapy depending on the treatment protocol
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Radiation Therapy for Larynx Cancer
-usually over 6 weeks and in daily or twice-daily doses
-can be used in combination with surgery
:they will use radiation to shrink the tumor and then use surgery to remove it
-commonly an outpatient procedure (come in, do treatment, go home)
-if the tumor is very small and they can pinpoint the location, they can have an 80% cure rate
*nursing interventions
:hoarseness may become worse during radiation treatment
:reassure patient/family that voice will improve to at least pre-treatment levels 4-6 weeks after treatment
:the voice will not return to normal, but it will go back to pre-treatment levels
:encourage patient to use voice rest and alternative means of communication
:write notes, sign words, etc.
:most patients will complain of swallowing difficulties and a sore throat while receiving therapy
:offer gargling with saline, sucking ice, and anesthetic mouthwashes/throat sprays
:pain medication as ordered for relief, such as Lortab
:if the salivary glands are irradiated, the patient will have a dry mouth
:this side effect may be permanent (make sure to tell the patient this)
:increased fluids, artificial saliva, chewing gum/candy, and humidification can help
:the skin at the site of irradiation becomes red, tender, and may peel
:the patient must avoid exposing this area to sun, heat, cold, and shaving
:patient is instructed to wear protective clothing made of soft cotton
:especially in cold weather
:patient is instructed to was the affected area with a mild soap such as Dove or Ivory
*only lotions/powders prescribed by the radiologist should be used until the area is healed
:some lotions can cause a major burn with radiation treatment
:some powders can cause a yeast infection or bacterial skin infection

Surgery for Larynx Cancer

-types of surgery
:cordal stripping
:cordectomy (excision of a vocal cord)
:partial laryngectomy (done when only one vocal cord is involved)
:total laryngectomy (for cancer that extends beyond the vocal cords or cancer that persists after radiation)
:this is where they take out everything including the voice box; the patient will not be able to talk
-with a partial laryngectomy, a temporary or permanent tracheostomy is done to protect the airway
-with total laryngectomy, the upper airway is separated from the pharynx and esophagus, and the trachea is
brought out through the skin in the neck and sutured in place, creating a stoma
:this airway opening is always permanent
-if the tumor invades surrounding lymph nodes in the neck or if the tumor is known to have a high rate of nodal
spread, a nodal neck dissection is done along with the removal of the primary tumor
-neck dissection includes the removal of the tumor-involved lymph nodes, the sternocleidomastoid muscle,
the jugular vein, the 11th cranial nerve (spinal accessory nerve), and surrounding involved soft tissue
-dissection of the 11th cranial nerve causes shoulder drop
:the patient will need physical therapy to help them increase the use of other muscle groups

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Laryngectomy
-this leads to a permanent loss of the voice as well as a change in the airway
:a total laryngectomy requires a permanent tracheal stoma
-after surgery, the patient may use esophageal speech
:they are taught how to belch which will cause explosions of air from the esophagus to produce speech
-another option for speech is to use an electric larynx
:this device that projects sound into the oral cavity
:the patient will have a mechanical sounding voice
-the patient may have a tracheoesophageal puncture
:a valve is placed in the tracheal stoma to divert air into the esophagus and out the mouth to speak
-with a total laryngectomy, a laryngectomy tube is placed
:this tube has a larger diameter than a tracheostomy tube (because they have a larger stoma)
-saline is used to clean the stoma
-nebulizers and humidifiers can be used to increase the humidity
:if it dries out it can be uncomfortable and increase the risk for infection
-when the stoma heals (3-6 weeks) the tube is removed
-complications of laryngectomy
:hemorrhage- from drains or surgical sites
:infection- check the surgical site for redness, swelling, and drainage
:also look at CBC, increased WBC’s, increased lymphocyte count, and pain
:wound breakdown- observe the stoma area for breakdown, hematoma, and bleeding
:if the wound does not heal properly, the carotid artery can rupture from erosion (this is usually fatal)
*patient teaching
:wear loose fitting protective clothing at the stoma (nothing tight, or they will not be able to breathe)
:cover the stoma when showering
:teach the patient to recognize signs and symptoms of complications (such as infection)
:make sure the patient knows how to clean their stoma and change the laryngectomy tube
:because they will have the tube in for 3-6 weeks after leaving the hospital

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Lung Cancer
-overall 5 year survival rate is only 14%
-prognosis remains poor unless tumor can be completely removed surgically
-over 90% of cases start in the bronchial epithelium
-tumors metastasize (spread) by direct extension, through the blood, and by lymphatic invasion
-tumors in the bronchial tubes can grow and obstruct the bronchus partially or completely
*tumors can grow so large that they cause airway obstruction by encircling the airway
:have to worry about restrictive airway disease
*tumors in the edges of the lungs spread and can compress lung structures such as the airway
:it can also compress the alveoli nerves, blood vessels, and lymph vessels
:the compression of other structures can cause difficulty breathing
-types of lung cancer
**know which cancer is caused by what (a smoker or non-smoker)
:large cell carcinoma (slow growing)
:11% of all lung cancer cases (one of the more rare forms of lung cancer)
:slow form of cancer
:have peripheral lesions on the lungs with necrotic surfaces and cavities
:small cell carcinoma (fast growing)
:most aggressive, is basically a death sentence
:20% of all lung cancer cases
:also called Oat Cell carcinoma
:tumors located centrally with very quick growth
:highest rate of metastasis through the lymph and circulatory systems
:most malignant form of lung cancer
:squamous cell carcinoma (slow growing)
:associated with smoking
:30% of lung cancer cases
:slower growing, less invasive form of lung cancer
:metastasis often limited to thorax, and it can go to the regional nodes and chest wall
:often have obstructive symptoms as well as pneumonia
:adenonacarcinoma (slow growing)
:most common in non smokers
:30-35% of lung cancer cases
:located peripherally and is slow growing
:most frequent type of cancer in women
-risks
:cigarette smoking causes 85% of lung cancer deaths (risk is directly related to “pack years”)
:pack years is how many a day times the number of years smoked
:nonsmokers exposed to passive smoke
:occupational exposure to asbestos, beryllium, chromium, coal distillates, cobalt, iron oxide, mustard gas,
petroleum distillates (oil rigs), radiation, tar (construction), nickel, and uranium
*health promotion
:quit smoking (quit all forms of tobacco and all forms of smoking)
:avoid exposure to second hand smoke (especially with little children)
:educate workers in industrial settings about safety precautions
:such as wearing specialized masks and protective clothing (make sure mask fits properly)
:encourage people who are at high risk for lung cancer development to seek frequent health exams
:a 70 year old male who smokes 2 packs a day for 20 years needs to have chest x-ray yearly

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Lung Cancer (continued)
*signs and symptoms
:hoarseness
:persistent cough or change in cough
:blood streaked, rust colored, or purulent sputum
:blood streaked could also be tuberculosis
:hemoptysis (coughing up straight blood)
:dyspnea (shortness of breath)
:weight loss (this goes with any form of cancer)
:shoulder, arm, chest wall, or chest pain
:wheezing
:clubbing
:recurring episodes of pleural effusion, pneumonia, or bronchitis
-diagnostic tests
:chest x-ray (to see where the lesions are)
:CT scan (will give a better view of lesions)
:spiral CT is very accurate when looking or a specific type of cancer (is very expensive)
:will often pick up something that a regular CT or MRI might miss
:fiber optic bronchoscopy (*make sure gag reflex is back before giving anything by mouth)
:looks more at the tracheal bronchial tree, where the mucous is produced
:thorascopy (a video assisted thorascope that goes through the chest cavity)
:can directly visualize the lung tissue
:throacentesis
:needle biopsy
:direct surgical biopsy (this is done with a thorocotomy test)
:MRI
-medical management
:chemotherapy (*best for small cell lung cancer, because it spreads very rapidly)
:with chemo they try to get the cancer under control before they go in a remove the cancer
:radiation therapy (*used for locally advanced intrathoracic lung tumors)
:they can focus in on a specific area with radiation therapy
:spiral CT is used to pinpoint exactly where the tumor is
:same guidelines as for radiation for laryngeal cancer
-surgical management
:wedge resection- removal of the peripheral portion of a small localized area of disease
:with some of the small, peripheral growing cancers, they just cut our the area of cancer
:segmental resection- a pulmonary resection
:includes the bronchus, pulmonary artery and vein, and lung parenchyma of the involved lung segment
:lobectomy- removal of the entire lobe (most common)
:pneumonectomy- removal of entire lung
:thorocotomy- crack the chest wall and do a biopsy and take out diseased portion of the lung

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Lung Cancer (continued)
*preoperative care
:relieve anxiety (through education of what to expect)
:reinforce the surgeon’s explanation of the surgical procedure
*make sure they are truly given an informed consent
:provide education related to postoperative care
:teach the anticipated location of the surgical incision
:teach shoulder exercises
:teach about chest tubes (there is no chest tube with a pneumonectomy, because the lung is gone)
:teach importance of turning, coughing, deep breathing, and incentive spirometer
*postoperative care
:patient will have some form of oxygen therapy, most likely a nasal cannula
:may be on a mask if a whole lung is taken out
:encourage patient to use their incentive spirometer every hour while awake
:monitor respirations closely (may have PCA or epidural for pain)
:turn, cough, and deep breathe every 2 hours
:change dressings as ordered
:closely observe patient for signs and symptoms of infection and respiratory distress
:after having a thoracotomy, the patient will have at least one chest tube to drain air and blood that
may accumulate in the pleural space (air and blood causes positive pressure and lung will collapse)
:the chest tube restores negative intrapleural/intrathoracic pressure and allows re-expansion of the lung
:with 2 chest tubes
:one towards the apex of the lungs gets out excess air
:one towards the lateral/base side gets out excess fluid

Pleuravac
-most commonly used chest tube drainage system
-from right to left the system contains chambers for drainage, a water seal, and suction control
*sterile gauze and tape are kept at the bedside to cover the insertion site immediately if the chest tube
becomes dislodged (tape down three corners and leave the fourth corner open for air to get out)
-if chest tube is pulled out, cover with sterile gause, and then call the physician STAT
-three chambers
:first chamber- is the collection chamber
:this is where you look to evaluate how much drainage there is
:mark the level that you record with a marker
:tape the chamber to the floor so it is not tipped over (if it is tipped over, get a new container)
:second chamber- is the water-seal chamber that prevents air from entering the pleural cavity
:normal for water to rise 2-4” during inhalation and fall during exhalation (*called tidaling)
:third chamber- is where suction is hooked up

Chest Tubes
-check the water seal chamber for unexpected bubbling created by an air leak in the system
:if you see bubbling that is nonstop, you need to suspect an air leak (make sure everything is in tact)
-bubbling is normal during forceful expiration or coughing because the air in the chest is being expelled
:if they have forceful expirations (coughing, laughing), you may see bubbling, but it will stop
-continuous bubbling indicates an air leak that must be identified

Pneumonectomy Care
-patient is placed on the non-operative side immediately after surgery
:positioning on the operative side places increased stress on the bronchial stump incision
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Bronchiectasis
-a disorder characterized by permanent, abnormal dilation of one or more of the large bronchi
:this leads to destruction of the elastic and muscular structures of the bronchial wall
:this causes an interference with air exchange
-predisposing factors
:obstructive processes
:lung masses
:COPD
:thick secretions found in cystic fibrosis or bronchitis
:aspirated foreign bodies (especially with small kids)
:obstructive processes cause the bronchi/ bronchioles to distend and provide a place for organisms to grow
:you have to worry about pneumonia and infections
*clinical signs and symptoms
:chronic productive cough with copious mucopurulent sputum
:hemoptysis (coughing up straight blood)
:recurrent pneumonia accompanied by crackles, diminished breath sounds, rhonci, and wheezing
:atelectasis is the major complication that occurs due to the obstruction (get impaired gas exchange)
-treatment
:antibiotics (if bacterial infection)
:bronchodilators (try to open up the bronchioles)
:expectorants (to thin out the mucous so they can cough it up; ex: Mucinex)
:chest physiotherapy (especially with cystic fibrosis to help mobilize the secretions)
:occasionally see surgical resection of a lobe or a segment

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Tuberculosis
-this disease is increasing
-epidemiological map: Latin America, Subsarharian Africa, certain parts of Asia have high incidence
:make sure the person has not been around TB, they could have it and not know it
-is caused by Mycobacterium tuberculosis
-when an infected person coughs, laughs, or sneezes, droplet nuclei are produced
:these droplets become airborne and may be inhaled by others
-the tubercle bacillus multiplies when it reaches susceptible sites (bronchi or alveoli)
-a granuloma forms in the lung tissue once they get the disease
-due to noncompliance with medications, there are now drug resistant strains
*populations at risk
:anyone around an untreated infected person
:HIV or immunosuppresed (transplant patients because of immunosuppressant drugs)
:living in crowded areas (prison)
:IV drug abusers
:homeless
:lower socioeconomic group
:foreign immigrants (especially from Mexico, Vietnam, Philippines, and Sub Saharan Africa)
*signs and symptoms
-these are easy to confuse with lung cancer
:progressive fatigue
:lethargy
:nausea
:anorexia
:weight loss
:irregular menses
:low grade fever (99-100o)
:cough
:night sweats
:mucopurulent sputum that is occasionally streaked with blood (can be straight blood if more advanced)
:chest tightness
:dull, aching chest pain
*diagnosis
:positive smear for acid-fast bacillus
:this is used as a quick method to determine whether TB treatment and precautions should be started
until more definitive testing is done
:three smear samples are usually taken (the most common way to diagnose)
:after meds are started, smear checked again to check effectiveness of therapy
:most people have negative smears after 3 months of treatment
:may do culture and sensitivity to determine the best drug to use
:sputum culture confirms the diagnosis (the gold standard, but it takes time to get the result back)
:it can take 1-3 weeks to get positive or negative result
:TB test (Mantoux test)
:induration 10mm or higher diameter means patient exposed to/infected with TB
*does not mean you have it, it means you have been exposed
:induration of 5mm or higher is a positive result in patients who are immunocompromised
:immunocompromised include cancer patients, transplant patients, HIV/AIDS infection
:a reduced skin reaction or negative skin test does not rule out TB infection
:especially among the very old or anyone severely immunocompromised
:if positive skin test a chest x-ray is done to rule out clinically active TB or to detect old, healed lesions
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Tuberculosis (continued)
-treatment
:combination drug therapy is used (drug therapy can last from 6-12 months)
:look at what country they have been to determine the strain and what drug to use
:Isoniazid (INH) and Rifampin are used throughout treatment
*Isoniazid can cause hepatitis and neurotoxicity
*most patients receive B6 to prevent peripheral neuropathy
* Rifampin can cause hepatoxic effects (the urine will turn orange)
:Pyranzinamide is added for the first 2 months
:Ethambutol or Streptomycin are added as the 4th drug
*Ethambutol can cause problems with visual acuity
*Streptomycin may cause hearing and vision problems
*precautions for a patient with tuberculosis
:patient will be in a negative air flow isolation room (this keeps the air in the room out of the halls)
:a positive airflow room is for cancer patients to protect them
:health care workers wear a N95 or HEPA mask when in the room
:if there is a risk of contaminating clothing, a gown is worn
*patient education
:drug therapy and compliance
:all members of the patient household need to get tested for tuberculosis
:instruct the patient to cover their mouth and nose when coughing or sneezing
:place the used tissues in a plastic bag
:instruct the patient it wear a mask when in contact with crowds until the medication is effective
in suppressing the infection (about 2-3 months after drug therapy begins)
:sputum (acid fast test) needs to be examined every 2-4 weeks when on drug therapy
:this is to make sure the drug therapy is being effective
:when the results of 3 sputum cultures are negative the patient is no longer considered infectious and
can usually return to employment

Chronic Obstructive Pulmonary Disease

*read the book sections on this!

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