Chapter 39 Assisting in Pulmonary Medicine PDF

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Chapter 39: Assisting in Pulmonary Medicine

Function of the Respiratory System   

Exchanges oxygen from the atmosphere for carbon dioxide waste Maintains the acid-base balance in the body What is the difference between respiratory acidosis and alkalosis? (Respiratory acidosis occurs if the patient experiences hypoventilation and carbon dioxide levels increase in the body, causing hypercapnia. Respiratory alkalosis is related to an excess release of carbon dioxide caused by hyperventilation, which may be associated with anxiety or an acute asthma attack. Both conditions can be life-threatening if the underlying causes are not corrected.)

The Respiratory System  

Figure 39-1 shows the thoracic cage. A, Anterior. B, Posterior. The thoracic cage, or rib cage, protects the organs in the chest cavity.

Requirements for Normal Respiration      

An open airway leading to the lungs Ability of the lungs to expand rhythmically Intact alveolar membranes Coordination of the intercostal muscles and the diaphragm Proper action of the central nervous system’s respiratory control center The respiratory system is divided into two anatomic regions, the upper respiratory tract and the lower respiratory tract.

Anatomic Structures of the Respiratory System   

Figure 39-2 shows anatomic structures of the respiratory system. The upper respiratory tract, which transports air from the atmosphere to the lungs, includes the nose, pharynx (throat), and larynx. The lower respiratory tract consists of the trachea, bronchial tubes, and lungs.

Bronchial Tree  

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Figure 39-3 shows the bronchial tree. The bronchial tree and alveoli are the major structures housed within the right and left lungs. The lungs are soft and spongy because of the air sacs that make up most of their mass. Are both lungs the same size and shape? (No, the right lung is divided into three lobes and has a greater volume capacity than the left lung.)

Lobes of the Lungs   

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Figure 39-4 shows the lobes of the lungs. Because each lobe has its own bronchus and blood supply, the removal of one lobe (lobectomy) results in little or no damage to the rest of the lung. The left lung is longer and narrower and has a distinct indentation in its center, known as the cardiac notch, where the left ventricle of the heart is located, and an apical pulse is heard. The lung has two membranes: the pleural membrane and the visceral membrane. Small amounts of pleural fluid fill the space between the two membranes and provide lubrication for the movement of the lungs during inhalation and exhalation.

Ventilation       

Bronchioles deposit oxygenated air into alveoli Surrounding capillaries fill with waste air, exchange with oxygen-rich air in alveoli This gaseous exchange is ventilation Inspiration is taking air from atmosphere into alveoli Movement of waste gases from alveoli into atmosphere is expiration Inspiration begins with a signal from the medulla oblongata in the brainstem because of a decrease in blood oxygen levels or increase in carbon dioxide. Once inspiration is complete, diaphragm and intercostal muscles relax to expel air from lungs.

Alveoli with Their Capillary Network

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Figure 39-5 illustrates alveoli with their capillary network. Respiratory distress occurs when an individual is unable to move an adequate amount of air into the lungs, using the diaphragm and intercostal muscles, to meet the body’s needs. In certain respiratory conditions, such as asthma or emphysema, the person has difficulty getting air out of the lungs, and accessory muscles in the chest and abdomen are needed to assist the intercostal and diaphragm muscles for complete exhalation.

Respiratory Defenses     

System

Upper respiratory tract has mucus-covered ciliated surfaces of membranes to trap particles, which are then sneezed out or swallowed Lower respiratory tract is sterile; the ever-changing airflow creates a turbulence inhospitable for invading substances Coughing, sneezing, and immune system protect the respiratory system Disease occurs when something disrupts the normal homeostatic chain of events. Familiarize yourself with all respiratory terms in Table 39-1.

Major Diseases of the Respiratory System: Infectious Diseases

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Diseases of the nose and upper respiratory tract are more common than diseases of the lower respiratory tract Most lung infections are seen in hospitalized patients, the elderly, substance abusers, alcoholics, and patients with acquired immunodeficiency syndrome (AIDS) How common are respiratory tract infections? (They account for approximately 75% of all clinically diagnosed infections. Only about 5% involve the lungs.)

Common Cold     

Viral inflammatory process affecting mucous membranes lining the nose, pharynx, larynx, and bronchus Can be followed by bacterial infections of the pharynx, sinuses, and middle ear Nasal congestion and rhinorrhea, sneezing, watery eyes, pharyngitis (sore throat), laryngitis (hoarseness), and coughing Rest and drink fluids, usually runs its course in 3 to 5 days An over-the-counter (OTC) cold remedy, cough syrup, and acetaminophen may lessen the discomfort of cold-related symptoms.

Sinusitis   

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Each sinus has an opening into the nose for a free exchange of air and is lined with a continuous mucous membrane Infection or an allergic reaction can cause one or more of the sinuses to become inflamed Inflammation causes edema and collection of mucus within sinus cavity, creating a feeling of pressure, nasal congestion or rhinorrhea, and classic sinus headaches What are treatment options for sinus infections? (The condition is treated with decongestants, antibiotics for bacterial infections, and analgesics. Sinusitis can be acute, lasting 2 to 8 weeks, or chronic, with symptoms lingering much longer.)

Allergic Rhinitis (Hay Fever)    

Allergic rhinitis frequently is confused with an infectious disease Caused by a reaction of nasal mucosa to an environmental allergen Signs and symptoms include sneezing, nasal congestion, nasal itching, and rhinorrhea What symptoms help distinguish rhinitis from a cold? (The condition usually is an allergy if the eyes, ears, nose, throat, and roof of the mouth [palate] are itchy; the eyes are red and watery; a clear, thin nasal discharge is present; symptoms are seasonal and last for weeks or months; and the individual does not have a fever.)

Types of Pneumonia

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Figure 39-6 illustrates types of pneumonia. Pneumonia is both a specific disorder and a general term meaning inflammation of all or part of the lungs. Pneumonia can be caused by bacteria, viruses, or other pathogens; it affects preschoolers and the elderly most often. If the invading organism is bacterial, the treatment of choice is antibiotics and lung function therapy until the patient has recovered. If the organism is viral, the patient is given supportive care, such as antipyretics, fluids, and oxygen, until the immune system can control the spread of the virus. Refer to Table 39-2, Pathogens That Cause Pneumonia.

Tuberculosis      

Tuberculosis (TB) causes more deaths than any other infectious agent in the world Vaccine does not always provide protection from the disease Caused by the bacterium Mycobacterium tuberculosis and spread by droplets of sputum Primary infection occurs and lungs become inflamed; when tubercles are reactivated, secondary, or active TB, can develop Active TB is treated with long-term drug regimen to eradicate the bacilli What typically occurs in a healthy person exposed to primary infection? (Cellmediated immunity ensues, isolating the bacteria and forming a tubercle. At

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this point a healthy individual can stop the spread of infection, causing the TB bacillus in the tubercle to become inactive. In this case, the person was exposed to the pathogen but never developed active disease and so is said to have a latent TB infection, which is not contagious.) As the infection becomes virulent in the host, a productive cough develops, and thick, dark, frequently blood-tinged mucus is expectorated. All tuberculin-negative healthcare workers should have a purified protein derivative (PPD) test annually; workers who show a positive reaction but are not actively infected with TB should have an annual chest x-ray evaluation to screen for the disease.

Chronic Obstructive Pulmonary Disease    

Group of diseases with the common characteristic of chronic airway obstruction Chronic bronchitis, bronchiectasis, asthma, pneumoconiosis, and emphysema o Mostly due to smoking Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in America, and most of those deaths are related to smoking. Although the mechanism of the obstruction may vary, a patient with COPD is unable to ventilate the lungs freely, which results in an ineffective exchange of respiratory gases, dyspnea, and productive cough.

Asthma       

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Inflammation and bronchospasm with resultant airflow obstruction; may become chronic Nonproductive cough, dyspnea, expiratory wheezing, chest tightness, difficulty breathing Teach the patient to perform peak flow measurements to assess air flow During an asthma attack, medical intervention is required (e.g., “rescue” inhalers) Anti-inflammatory medications and nebulizers are also used Patient teaching is very important to ensure that the patient operates the device correctly so that the medication can be administered as ordered. If both a steroid and a bronchodilator have been prescribed, the bronchodilator should be taken first because this opens the airways so that the steroid is better distributed throughout the lungs. Procedure 39-1 describes how to teach a patient to use a peak flow meter. Procedure 39-2 outlines the procedures for administering a nebulizer treatment.

Patient Education for a Metered-Dose HFA Inhaler

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Instruct the patient in the use of a metered-dose inhaler as follows: o Shake the canister vigorously and place it into the mouthpiece device o Open mouth and hold canister approximately 1 inch away o Exhale normally. Then, while beginning to inhale slowly, depress the canister, releasing a metered dose of medication. o Continue to breathe in until your lungs are full; hold the breath to a count of 10 and breathe out normally o If a second dose has been prescribed, wait at least 1 minute between puffs Some inhalers come attached to spacers or can be adapted to meet the needs of children or older patients who have difficulty managing the technique. Refer students to Figure 39-11 to see an inhaler with a spacer.

Pneumoconioses    

Most of these respiratory diseases are occupational; consequence of longterm exposure to unsafe air in the workplace Coal mining (anthracosis); insulation manufacturing and shipbuilding (asbestosis); and stonecutting or sandblasting (silicosis) Dyspnea, cough, and emphysema-like changes; increased risk of lung cancer What does the inhalation of these materials do to the lungs long-term? (Irreversible damage to the lung tissue occurs.)

Emphysema      

Progressive obstructive disease of the pulmonary system that is irreversible Loss of elasticity in the walls of the alveoli; eventually these walls stretch and break Cigarette smoking is the primary contributing factor, but other factors include pollutants or chronic respiratory disorders Dyspnea, shortness of breath, wheezing, production of thick mucus, restlessness, fatigue, anorexia, persistent cough, peripheral cyanosis Patients with emphysema are encouraged to avoid respiratory irritants and individuals with respiratory infections and to stop smoking. Patients with emphysema expend a great deal of energy just to expel air from the lungs, so they should consume a high-calorie, high-fluid diet and perform certain exercises, such as pursed-lip breathing, to help them conserve energy.

Obstructive Sleep Apnea

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Relaxation of the posterior pharynx muscles during sleep, causing the trachea to narrow or close, momentarily stopping breathing Interrupts sleep, causing fatigue Risk factors include being overweight, having enlarged adenoids or tonsils, male gender, alcohol and sedative use More prone to hypertension, heart disease, memory problems, headaches, depression Blood oxygen levels are lowered, and the brain senses hypoxemia so it stimulates the patient from sleep to reopen the trachea. Why does being overweight increase risk of getting sleep apnea? (Individuals are at greater risk of developing obstructive sleep apnea if they are overweight because a fat or thick neck may narrow the trachea.)

Continuous Positive Airway Pressure (CPAP) Machine  

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Figure 39-13 shows a patient with a CPAP machine. Sleep apnea typically is treated with a continuous positive airway pressure (CPAP) machine, which delivers air pressure through a mask placed over the mouth or through a cannula in the nose. Patients may have to experiment with different types of masks and need to be encouraged to follow through with the recommended treatment.

Lung Cancer     

Ninety percent of lung tumors are linked to cigarette smoking Lung is a common site of secondary tumors from metastasis Early symptoms include chronic cough, shortness of breath, and chest tightness Unless diagnosed very early, the prognosis is poor even with surgery, radiation, and chemotherapy How does the cessation of smoking affect one’s risk of getting lung cancer? (Individuals who quit smoking can significantly lower their risk of lung cancer; after 10 years, the risk is reduced by one third.)

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Other risk factors include chronic exposure to second-hand smoke, carcinogens (e.g., radon gas and asbestos), and a genetic predisposition.

Carcinoma of the Larynx     

Linked to smoking and chronic alcohol consumption Ninety percent of cases of laryngeal cancer occur in men Hoarseness, loss of voice, and dysphagia Surgical treatment consists of a partial or total laryngectomy What is the difference between a total and partial laryngectomy? (With a total laryngectomy, the voice is permanently lost, and a tracheostomy is performed.)

Assisting with the Examination   

Have the patient disrobe to the waist and put on a gown Assist the physician, provide privacy and support for the patient, and perform diagnostic tests as ordered To assess the status of the respiratory system, the physician uses inspection, palpation, percussion, and auscultation on the anterior thorax, then repeats the process on the posterior and lateral thorax.

Diagnostic Procedures: Tuberculosis    

Administer the Mantoux test Intradermal injection of PPD is given Positive Mantoux reaction indicates latent or active TB Further testing using chest x-ray examination and sputum culture is required for a definitive diagnosis.

Spirometry   

Figure 39-16 shows a spirometer. Lung function measurements are taken with a spirometer. Prepare the patient, explain and perform the procedure, and determine the results.

Spirometry

Procedure

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Chin should be slightly elevated, and the neck slightly extended Take as deep a breath as possible Blow air out hard Do not stop blowing until you are told to stop You may need to raise your voice with some urgency to improve the patient’s performance, using such phrases as, "Blow, blow, blow!" "Keep blowing, keep blowing!" and "Don’t stop blowing!" Continue to repeat efforts until the patient has completed three acceptable maneuvers. The two best efforts are used to calculate pulmonary function. Procedure 39-3 describes how to perform volume capacity spirometry testing.

Spirometry Test Results  

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Place the results of maneuvers with the patient’s medical record on the physician’s desk If results are less than 60% of the predicted value, the patient may be given bronchodilators and be retested to determine the impact of the inhalant on the function Ask the patient to wait while the physician reviews the results How are the results calculated? (The physician calculates normal values for each patient based on the individual’s age, height, weight, and gender; the test results are documented as a percentage.) If the patient has delayed taking medication, check with the physician as to when the patient should resume taking it.

Pulse Oximetry      

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Noninvasive method of evaluating the pulse rate and oxygen saturation of hemoglobin in arterial blood Identifies percentage of the hemoglobin that is oxygenated in comparison with the total amount of hemoglobin available Used to assess a patient’s oxygenation status in disorders such as pneumonia, bronchitis, emphysema, or asthma. Figure 39-17 shows a pulse oximeter. A pulse oximeter is used to assess a patient’s oxygenation status in disorders such as pneumonia, bronchitis, emphysema, or asthma. To perform the pulse oximetry procedure, the medical assistant clips a probe on the patient’s earlobe or finger and an infrared beam passes through the tissue, measuring oxygenated hemoglobin. At the same time, the pulse rate is measured. What is a normal reading? (A normal pulse oximetry reading is 95% or higher.) Treatment, such as oxygen or bronchodilator therapies, usually is started when readings are 90% to 92% or lower.

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Refer to Procedure 39-4 for steps on how to perform pulse oximetry.

Obtaining Sputum for Culture 

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Requested when the signs and symptoms are accompanied by physical evidence of pneumonia, TB, or other infectious diseases of lower respiratory tract Sample is cultured and incubated, and the pathogenic organism grown in the culture medium is identified Sample may also be sent to the laboratory for cytologic analysis A cytologic analysis test is used to test for what condition? (A cancerous condition of the lungs or bronchi) Procedure 39-5 describes how to obtain a sputum sample for culture.

Methods of Sputum Collection 

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Expectoration is most common o Instruct patient to do the following:  First thing in morning, cough deeply, and collect 1 teaspoon into specimen cup o Return to the office or laboratory as soon as possible Other methods include tracheal suctioning and a bronchoscopy in the office The medical assistant may be responsible for explaining the procedure to the patient or reinforcing the physician’s instructions. If the patient is taking antibiotic medications at the time of the specimen collection, this information should be included on the laboratory slip.

Bronchoscopy   

You may schedule the test, instruct the patient on preparation, and help answer questions Provides an endoscopic view of the larynx, trachea, and bronchi Physician uses a fiberoptic instrument to view and collect tissue samples

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Patient should not eat or drink 4 to 8 hours beforehand and perform good mouth care Patient is sedated and a topical anesthetic is used; therefore, it is not an uncomfortable procedure The patient should be reassured that the procedure does not interfere with breathing. The tube can be inserted through the nose or mouth, and as it reaches the glottis, more lidocaine is sprayed to control the cough reflex. The physician continues to pass the tube through the bronchi and larger b...