NCLEX-RN Exam Prep: Care of the Client with Respiratory Disorders

According to the American Lung Association (2006), lung disease is the fourth leading cause of death in the United States. More than 35 million Americans live with chronic lung disease. Some of these diseases, such as asbestosis, are the result of occupational exposure and carry associated risks of lung cancer. Respiratory infections, particularly nosocomial pneumonia, are responsible for 11% of all hospital-acquired infections. This chapter covers common noninfectious disorders that contribute to chronic lung disease, occupational lung disorders, infectious diseases of the lower respiratory tract, acute respiratory disorders that threaten the client's life, and emerging pulmonary infections.

Noninfectious Disorders of the Lower Respiratory Tract

Noninfectious disorders of the lower respiratory tract affect the exchange of oxygen and carbon dioxide. The chronic and progressive nature of many of these disorders, such as emphysema, result in major changes in the person's lifestyle. Others, such as asbestosis and berylliosis, result from occupational exposure and increase the risk of lung cancer and premature death. Although many noninfectious disorders of the lower respiratory tract are preventable, other disorders—such as sarcoidosis—are not. This section reviews the chronic obstructive disorders, pulmonary hypertension, interstitial pulmonary disease, and occupational pulmonary disease.

Chronic Bronchitis

Chronic bronchitis refers to an inflammation of the bronchi and bronchioles. It is caused by a continuous exposure to infections or noninfectious irritants, such as tobacco smoke. Unlike emphysema, bronchitis is confined to the small and large airways rather than the alveoli. Thickening of the bronchial wall and the production of thick mucus blocks the smaller airways and narrows the larger ones. Chronic bronchitis can often be reversed with the removal of irritants; however, it is complicated by respiratory infections and can progress to right-sided heart failure, pulmonary hypertension, and in some instances to acute respiratory failure. Chronic bronchitis is most common in those age 40–55 years.

Symptoms associated with chronic bronchitis include the following:

• Shortness of breath
• Cough (which might be more common in the winter months)
• Increased sputum production
• Difficulty in eating (due to shortness of breath)
• Decreased weight
• Sleep difficulty (need to sleep sitting up to facilitate breathing)
• Auscultation of fine or coarse crackles and wheezes
• Prolonged expiration time

Treatment of chronic bronchitis includes the use of bronchodilators, steroids, antacids, and expectorants. Antibiotics are usually ordered if the client has an acute respiratory infection. Attention is given to correcting acid-base imbalances, meeting nutritional needs, providing frequent oral care, and providing oxygen at low settings (2–3 liters per minute).

Emphysema

Emphysema is a condition in which there is an irreversible overdistention of the alveoli that eventually results in destruction of the alveolar wall. Clients with emphysema are sometimes described using the terms pink puffers or blue bloaters. Pink puffers (those with involvement of the bronchiole, alveolar duct, alveoli) experience exertional dyspnea yet remain pink. Blue bloaters (those with involvement of the secondary lobule resulting in changes in O₂ perfusion) have problems with chronic hypoxia, cyanosis, pulmonary edema, and sometimes respiratory failure. The blue bloater, who is cyanotic even at rest, experiences increasing dyspnea and deepening cyanosis with exertion. Polycythemia predisposes the client with emphysema to the development of clots.

Physical assessment of the client with advanced emphysema reveals the following:

• Presence of a barrel chest
• Digital clubbing
• Rapid shallow respirations
• Prolonged expiratory phase with grunting respirations
• Muscle wasting
• Weight loss
• Peripheral cyanosis
• Violent coughing productive of thick sputum

Chest x-ray reveals flattening of the diaphragm. Arterial blood gases typically reveal increased CO₂ levels and decreased O₂ levels. Pulmonary studies reveal increased residual volume and decreased vital capacity. Serum a ₁-antitrypsin levels are used to screen for deficiency of the enzyme, particularly in clients with a positive family history of obstructive airway disease, in those with early onset, women, and smokers who develop symptoms of COPD in their 40s. Normal adult serum a ₁ AT levels range from 80 to 260mg/dL.

Many of the symptoms for the client with chronic bronchitis and emphysema are the same; therefore, the treatment of both conditions includes the use of bronchodilators, steroids, antacids, and expectorants. Antibiotics are usually ordered if the client has an acute respiratory infection. Prophylactic antibiotics might be prescribed for clients who experience four or more respiratory infections per year. Immunization against pneumococcal pneumonia and yearly influenza vaccination are recommended to reduce the risk of respiratory infections. Attention is given to correcting acid-base imbalances, meeting nutritional needs, providing frequent oral care, and providing oxygen at low settings (2–3 liters per minute). a ₁-antitrypsin replacement therapy can be administered weekly by intravenous infusion for clients with emphysema due to genetic deficiency of the enzyme. Although expensive, the medication has been shown to reduce mortality rates.

Asthma

Asthma is the most common respiratory condition of childhood. Intrinsic (nonallergenic) asthma is precipitated by exposure to cold temperatures or infection. Extrinsic (allergenic or atopic) asthma is often associated with childhood eczema. Both asthma and eczema are triggered by allergies to certain foods or food additives. Introducing new foods to the infant one at a time helps decrease the development of these allergic responses. Easily digested, hypoallergenic foods and juices should be introduced first. These include rice cereal and apple juice.

Although asthma is the most common chronic disease of childhood, it can occur at any age. Many adults with asthma report having the disease in childhood.

Symptoms of asthma include expiratory wheeze; shortness of breath; and a dry, hacking cough, which eventually produces thick, white, tenacious sputum. In some instances, an attack might progress to status asthmaticus, leading to respiratory collapse and death.

Management of the client with asthma includes maintenance therapy with mast cell stabilizers and leukotriene modifiers. Treatment of acute asthmatic attacks includes the administration of oral or inhaled short-term and long-term B2 agonists and anti-inflammatories as well as supplemental oxygen. The nurse should instruct the client in the proper use of the inhaler (metered-dose and dry-powder) as detailed in the sidebar that follows. Methylxanthines, such as aminophylline, are rarely used for the treatment of asthma. These drugs, which can cause tachycardia and dysrhythmias, are administered as a last resort. Antibiotics are frequently ordered when a respiratory infection is present.

Pleurisy

Pleurisy, (pleuritis) an inflammation of the pleural sac, can be associated with upper respiratory infection, pulmonary embolus, thoracotomy, chest trauma, or cancer. Symptoms include

• Sharp pain on inspiration
• Chills
• Fever
• Cough
• Dyspnea

Chest x-ray reveals the presence of air or fluid in the pleural sac. Management of the client with pleurisy includes the administration of analgesics, antitussives, antibiotics, and oxygen therapy. A thoracentesis is often necessary if there is pleural effusion. It is the nurse's responsibility to prepare the client for the procedure including positioning. The client can be positioned in one of the following ways:

• Sitting on the edge of the bed with her feet supported and with her head and arms resting on a padded over the bed table (see Figure 5.1)

  Figure 5.1 Client positioning for thoracentesis.

• Sitting astride a chair with her arms and head resting on the back of the chair
• Lying on her unaffected side with her head of the bed elevated 30°–45° (for clients unable to sit upright)

Following the thoracentesis, the nurse should assess the client for complications, including bleeding, hypotension, and pneumothorax.

Pulmonary Hypertension

Pulmonary hypertension results when constriction of blood vessels increases vascular resistance in the lungs. Pulmonary hypertension is diagnosed by systolic pressures greater than 30 mm Hg in the pulmonary artery. In some instances, the condition occurs as a complication of other lung disorders. In the case of primary pulmonary hypertension (PPH), there is no lung disorder and the cause remains unknown. Pulmonary hypertension seems to occur in families and is more common in women 20–40 years of age.

The most common symptoms associated with pulmonary hypertension are chest pain, dyspnea and fatigue in an otherwise healthy adult. Eventually, the right side of the heart fails.

The diagnosis of pulmonary hypertension is made by a right-sided heart catheterization that reveals increased pressure in the pulmonary artery. Pulmonary function tests show decreased pulmonary volumes and decreased diffusion capacity. Abnormal ventilation perfusion scan and abnormal spiral CT help to confirm the diagnosis.

Medical treatment of pulmonary hypertension includes the use of anticoagulants, vasodilators, cardiotonics, calcium channel blockers, bronchodilators and diuretics. Daily doses of Coumadin (warfarin) are given to achieve an international normalized ratio (INR) of 1.5–2.0. This elevated INR can prevent the common occurrence of thrombosis in situ. Cardizem (diltiazem) or other calcium channel blockers such as Procardia (nifedipine) are given to dilate blood vessels. Short-acting direct vasodilators can be used for clients who do not respond to calcium channel blockers. These short-acting direct vasodilators include intravenous Flolan (epoprostenol), intravenous Remodulin (treprostinol), and oral Tracleer (bosentan). The use of vasodilators is limited in the client with pulmonary hypertension because the medication can produce systemic hypotension. Instead, infusion of Adenocard (adenosine) into the pulmonary artery is recommended because it has a vasodilating effect that is specific to pulmonary circulation. Viagra (sildenafil) has been shown to cause preferential pulmonary vasodilation and is sometimes used to manage clients with primary and secondary pulmonary hypertension.

The cardiotonic drug Lanoxin (digoxin) and diuretics are indicated for the client with cardiac hypertrophy and cardiac failure. Bronchodilators improve hypoxemia and reduce pulmonary vascular resistance. Surgical management of pulmonary hypertension relies on whole lung transplant.

Interstitial Pulmonary Disease

Interstitial pulmonary disease, sometimes referred to as fibrotic lung disease, encompasses several lung disorders that share common characteristics. These characteristics include the following:

• Pathologic changes in the alveoli, blood vessels, and surrounding support tissue of the lungs instead of the airway
• Restriction in expansion and recoil rather than obstructive disease
• Thickening of lung tissue so that the lung becomes "stiff" or noncompliant with respirations

Sarcoidosis and idiopathic pulmonary fibrosis are two examples of interstitial pulmonary disease.

Sarcoidosis

Sarcoidosis is a multisystem disorder that is capable of producing granulomatous lesions in almost any organ or tissue. The disorder is believed to be a hypersensitive response to one or more agents such as bacteria, fungi, viruses, or chemicals.

Sites most commonly affected are the lungs, lymph nodes, spleen, liver, central nervous system, skin, eyes, and parotid glands. According to the American Lung Association (2006) more than 90% of clients with sarcoidosis have pulmonary involvement. In the lungs, granulomatous infiltration and fibrosis results in low lung compliance, impaired diffusing capacity, and decrease lung volume.

The disease is not gender specific; however, African Americans are affected 10 times more often than Caucasians with the onset occurring in the third and fourth decades of life.

The symptoms of sarcoidosis vary according to the system involved. Pulmonary symptoms include dyspnea, cough, hemoptysis, and congestion. Other symptoms include anorexia, fatigue, weight loss, and fever.

The diagnosis of sarcoidosis is made by chest x-ray and CT scan, which reveal disseminated miliary and nodular lesions in the lungs. Mediastinoscopy or transbronchial biopsy are performed to confirm the diagnosis. The presence of noncaseating granulomas is consistent with a diagnosis of sarcoidosis.

Some clients with sarcoidosis undergo remission without specific treatment. Others are treated with cytotoxic or immunosuppressive drugs. Commonly used medications include corticosteroids (prednisone), Plaquenil (chloroquine), Indocin (indomethacin), Imuran (azathioprine), and Rheumatrex (methotrexate).

Pulmonary Fibrosis

Pulmonary fibrosis or restrictive lung disease is most common in the older adult with a history of cigarette smoking or chronic exposure to respiratory irritants such as metal particles, wood fires, or organic chemicals. When the lungs are injured, an inflammatory process continues beyond the time of normal healing. Extensive fibrosis and scarring occur, leaving the alveoli damaged. Most persons with pulmonary fibrosis have progressive symptoms with few remissions. Even with proper treatment, most clients die within five years of diagnosis.

Early symptoms of pulmonary fibrosis include mild exertional dyspnea. As the disease progresses dyspnea and hypoxemia become more severe. Eventually the client continues to have hypoxemia even when high levels of oxygen are administered. The goal of treatment is to slow the disease process and to manage the client's dyspnea. Immunosuppressive drugs such as Cytoxan (cyclophosphamide) and Imuran (azathioprine) are used to reduce inflammation. Side effects of these drugs include immunosuppression, nausea, and hepatic damage. Lung transplantation is a curative therapy for pulmonary fibrosis.

Occupational Pulmonary Disease

Occupational pulmonary disease results when workers are exposed to organic and inorganic dusts or noxious fumes or aerosols. Factors affecting the development of occupational lung disease include the composition and concentration of the agent, the duration of exposure, and the individual's susceptibility to the irritant. Coexisting pulmonary irritants such as cigarette smoke increase the risk of certain types of lung cancer. Occupational pulmonary diseases include silicosis, pneumoconiosis (black lung), asbestosis, talcosis, and berylliosis.

The prevention of occupational pulmonary disease includes proper ventilation of the work environment and the use of protective gear, including face masks, hoods, and industrial respirators. Educational programs for smoking cessation improve overall health and help decrease the risk of occupational pulmonary disease. Workers exposed to asbestos and toxic dusts should be educated regarding health hazards to others from clothing and shoes. A copy of "right to know laws" should be available to all workers exposed to hazardous or toxic materials. Workers should be educated about hazardous or toxic substances they work with, effects of these substances on their health, and measures to protect themselves.

Silicosis

Silicosis is caused by the inhalation of silica dust, which produces nodular lesions throughout the lungs. These nodules eventually enlarge and coalesce, causing dense masses in the upper portions of the lungs. The lungs become unable to fully expand and secondary emphysema produces obstructive lung disease.

Silicosis affects 1–3 million workers in the United States. Persons employed as foundry workers and those employed in glass manufacturing, stone-cutting, and manufacturing of abrasives and pottery are at risk for silicosis. Finely ground silica found in soaps and polishes is particularly dangerous.

The client with acute silicosis complains of dyspnea, fever, cough, and weight loss. Those with chronic silicosis have symptoms of hypoxemia, restricted air flow, and right-sided heart failure.

There is no specific treatment for silicosis. Management usually includes the provision of supplemental oxygen as needed, bronchodilators, and diuretics for symptoms of right-sided heart failure.

Pneumoconiosis

Pneumoconiosis (black lung, coal miner's lung) results from inhalation of dusts that are a mixture of coal, kaolin, mica, and silica. When these particles are deposited in the alveoli and bronchioles, they are surrounded by macrophages that transport them to the terminal bronchioles. For a while, these deposits are removed by mucociliary action. However, in time, the clearance mechanism cannot remove the excessive dust load and macrophages and fibroplasts clog the bronchioles and alveoli, creating blackened dots on the lung. These blackened dots, known as coal macules, are the primary lesions of the disease. Enlarged and dilated bronchioles eventually produce localized emphysema.

Pneumoconiosis begins in the upper lobes of the lungs and with repeated exposure progresses to the lower lobes. Symptoms begin with a chronic productive cough similar to the cough of bronchitis. As the disease progresses, the client complains of shortness of breath and a cough productive of a black fluid. Later symptoms include those of right-sided heart failure.

Asbestosis

Asbestosis, the result of inhaling asbestos dust or fibers, produces diffuse pulmonary fibrosis that obliterates the alveoli. Federal laws restricting or eliminating the use of asbestos were passed when it was learned that asbestos posed a health hazard. Persons employed in asbestos mining and manufacturing, shipbuilding, and construction and demolition of buildings containing asbestos materials are at greatest risk. Examples of asbestos-containing materials include shingles, cement, vinyl asbestos tile, fireproof paints, filters, and brake linings.

Symptoms associated with asbestosis include progressive dyspnea, persistent dry cough, mild to moderate chest pain, anorexia, and weight loss. Pleural thickening and plaque formation reduce lung volume and oxygen and carbon dioxide exchange. The development of cor pulmonale and respiratory failure is common. Additional related diseases include asbestosis pleural effusion and malignant mesothelioma—a rare but fatal cancer of the pleura, peritoneum, or pericardium. The period of time between asbestos exposure and development of mesothelioma is long, ranging from 20 to 30 years. Depending on the person's health and time of diagnosis, the average survival time is 4–12 months.

Talcosis

Talcosis occurs after exposure to talc dust. Persons employed in the manufacture of paint, ceramics, cosmetics, roofing materials, and rubber goods are at greatest risk for the development of talcosis. The disease results in diffuse interstitial fibrosis that eventually results in restrictive lung disease. The symptoms are the same as those with other forms of restrictive lung disease.

Berylliosis

Berylliosis is more common in workers in industries in which metal is heated (steel mills or welding) or where metal is machined in such a way that a dust is created. There is a genetic component in some individuals that seems to increase susceptibility to the disease after exposure. Like talcosis, berylliosis produces interstitial fibrosis that results in restrictive lung disease.