RESPIRATORY SYSTEM

DISORDERS
 RHINITIS
• is a group of disorders characterized by inflammation
and irritation of the mucous membranes of the nose.
• It may be classified as nonallergic or allergic.
• It is estimated that 10% to 15% of the population of the
United States has allergic rhinitis
• Rhinitis may be an acute or chronic condition.
 Pathophysiology
• Nonallergic rhinitis
– may be caused by a variety of factors
including
• environmental factors
– Changes in temperature or humidity
– Odors
– Foods
– Infection
• age
• systemic disease
• Drugs (cocaine) or prescribed medications
 • Drug-induced rhinitis is associated with
use of antihypertensive
• agents and oral contraceptives and
chronic use of nasal decongestants.
• Rhinitis
– also may be a manifestation of an
allergy
– referred to as allergic rhinitis and
sinusitis.
 Clinical Manifestations
• rhinorrhea (excessive nasal drainage, runny
nose)
• nasal congestion
• nasal discharge (purulent with bacterial rhinitis)
• nasal itchiness
• sneezing.
• Headache may occur, particularly if sinusitis is
also present.
 Medical Management

• depends on the cause

• Viral rhinitis is the cause - medications
are given to relieve the symptoms.
• Allergic rhinitis - to identify possible
allergens.
• Desensitizing immunizations and
corticosteroids may be required
• Bacterial infection - antimicrobial agent
 PHARMACOLOGIC THERAPY

• Medication therapy for allergic and nonallergic

rhinitis focuses on symptom relief.
• Antihistamines: sneezing, itching, and rhinorrhea.
• Oral decongestant agents : nasal obstruction.
• Intranasal corticosteroids : severe congestion
• Ophthalmic agents : relieve irritation, itching, and
redness of the eyes.
 VIRAL RHINITIS (COMMON
COLD)
• The term “common cold”: used when
referring to an upper respiratory tract
infection that is self-limited and caused by
a virus (viral rhinitis).
• Nasal congestion, rhinorrhea, sneezing,
sore throat, and general malaise
• Specifically, the term “cold” refers to an
afebrile, infectious, acute inflammation
 VIRAL RHINITIS (COMMON
COLD)
• highly contagious
• virus is shed for about 2 days before the
symptoms appear and during the first part
of the symptomatic phase.
• average two to four colds each year.
• the most common cause of absenteeism
from work and school
• The six viruses known to produce the signs
and symptoms of the viral rhinitis are
– Rhinovirus
– parainfluenza virus
– Coronavirus
– respiratory syncytial virus (RSV)
– influenza virus
– adenovirus
 Clinical Manifestations
• nasal congestion • general malais
• Runny nose • low-grade fever
• Sneezing • Chills
• nasal discharge • headache
• nasal itchiness • muscle aches.
• tearing watery eyes
• “scratchy” or sore
throat
 Medical Management
• no specific treatment for the common cold or influenza.
• Symptomatic therapy.
• Some measures include
– providing adequate fluid intake
– encouraging rest
– increasing intake of vitamin C
– using expectorants as needed.
– Warm salt-water gargles soothe the sore throat
– nonsteroidal anti-inflammatory agents (NSAIDs) such
as aspirin or ibuprofen relieve the aches, pains, and
fever in adults.
– Antihistamines are used to relieve sneezing, rhinorrhea,
– Nasal congestion. Topical (nasal) decongestant agents
 ACUTE SINUSITIS
• Sinuses
– mucus-lined cavities filled with air that drain normally into
the nose
– are involved in a high proportion of upper respiratory tract
infections.
– If their openings into the nasal passages are clear, the
infections resolve promptly.
• drainage is obstructed by a deviated
septum or by hypertrophied turbinates,
spurs, or nasal polyps or tumors, sinus
infection may persist as a smoldering
secondary infection or progress to an
acute suppurative process (causing
purulent discharge).
 Pathophysiology

• Acute sinusitis
– is an infection of the paranasal sinuses.
• Frequently develops as a result of an upper
respiratory infection, such as an
– unresolved viral or bacterial infection
– an exacerbation of allergic rhinitis.
– Nasal congestion, caused by inflammation,
edema, and transudation of fluid, leads to
obstruction of the sinus cavities
• This provides an excellent medium for
bacterial growth.
• occupations.
– hazards such as paint, sawdust, and
chemicals
• Bacterial organisms account for more than
60% of the cases of acute sinusitis, namely
– Streptococcus pneumoniae
– Haemophilus influenzae, and Moraxella
catarrhalis
– Dental infections also have been associated with
acute sinusitis.
 Clinical Manifestations
• facial pain or pressure over the affected sinus area
• nasal obstruction
• fatigue
• purulent nasal discharge
• Fever
• Headache
• ear pain and fullness
• Dental pain
• Cough
• a decreased sense of smell
• sore throat
• eyelid edema or facial congestion or fullness.
 Assessment and Diagnostic
Findings
• careful history and physical examination
are performed.
– The head and neck, particularly the nose,
ears, teeth, sinuses, pharynx,
and chest, are examined.
- tenderness to palpation over the infected
sinus area.
- The affected area is also transilluminated;
with sinusitis,
 Assessment and Diagnostic
Findings
• Sinus x-rays may be performed to detect sinus
opacity, mucosal thickening, bone destruction,
and air–fluid levels.
• Computed tomography scanning of the sinuses
is the most effective diagnostic tool.
– It is also used to rule out other local or
systemic disorders, such as tumor, fistula,
and allergy
 CHRONIC SINUSITIS

• is an inflammation of the sinuses that

persists for more than 3 weeks in an
adult and 2 weeks in a child.
 Pathophysiology

• A narrowing or obstruction in the ostia

of the frontal, maxillary, and anterior
ethmoid sinuses usually causes chronic
sinusitis, preventing adequate drainage
to the nasal passages.
 Pathophysiology

• Blockage that persists for greater than 3

weeks in an adult may occur because
of infection allergy, or structural
abnormalities.
• This results in stagnant secretions, an
ideal medium for infection.
 Pathophysiology

• organisms that cause chronic sinusitis

are the same as those implicated in
acute sinusitis
• Immunocompromised patients,
– risk for developing fungal sinusitis.
– Aspergillus fumigatus
• most common
 Clinical Manifestations

• impaired mucociliary clearance and

ventilation
• cough (because the thick discharge
constantly drips backward into the
nasopharynx)
• Chronic hoarseness
• Chronic headaches in the periorbital area,
and facial pain.
• symptoms are generally most pronounced
on awakening in the morning.
• Fatigue and nasal stuffiness are also
common.
• decrease in smell and taste and a fullness
in the ears.
 Assessment and Diagnostic
Findings
• history and diagnostic assessment
• Computed tomography scan
• magnetic resonance imaging (if fungal
sinusitis is suspected), are performed to
rule out other local or systemic
disorders, such as tumor, fistula, and
allergy.
• Nasal endoscopy
 Complications

• severe orbital cellulitis

• subperiosteal abscess
• cavernous sinus thrombosis
• Meningitis
• Encephalitis
• ischemic infarction.
 Medical Management
• The antimicrobial agents of choice include
– amoxicillin clavulanate (Augmentin) or ampicillin
(Ampicin).
– Clarithromycin (Biaxin) and third-generation
cephalosporins such as cefuroxime axetil (Ceftin),
cefpodoxime (Vantin), and cefprozil (Cefzil) have also
been effective
– . Levofloxacin (Levaquin) a quinolone
– 3 to 4 weeks.
– Decongestant agents, antihistamines, saline sprays,
and heated mist
 SURGICAL MANAGEMENT

• Excising and cauterizing nasal polyps,

correcting a deviated septum
• Incising and draining the sinuses
• aerating the sinuses, and removing
tumors
 Nursing Management

• promote sinus drainage by

– increasing the environmental humidity (steam bath, hot
shower, and facial sauna)
– increasing fluid intake, and applying local heat (hot wet
packs).
• follow the medication regimen.
• Instructions on the early signs of a sinus infection
are provided and preventive measures are
reviewed.
 ACUTE PHARYNGITIS

• inflammation or infection in
the throat, usually causing
symptoms of a sore throat.
 Pathophysiology

• viral infection
• group A beta-hemolytic streptococcus
– the most common bacterial organism,
– causes acute pharyngitis, the condition is
known as strep throat
• The body responds by triggering an
inflammatory response in the pharynx.
• pain, fever, vasodilation, edema, and tissue
damage, manifested by redness and swelling
in the tonsillar pillars, uvula, and soft palate.
• creamy exudate may be present in the
tonsillar pillars
• Uncomplicated viral infections
– subside promptly
– within 3 to 10
• group A beta-hemolytic streptococci
– is a more severe illness.
– left untreated, the complications can be
severe and life-threatening.
• Group A beta-hemolytic streptococci
– Complications include
• Sinusitis
• otitis media
• peritonsillar abscess
• Mastoiditis
• cervical adenitis
• In rare cases may lead to
– Bacteremia
– Pneumonia
– Meningitis
– rheumatic fever
– nephritis
 Clinical Manifestations

• fiery-red pharyngeal membrane and tonsils

• Swollen lymphoid follicles flecked with white-
purple exudate
• enlarged and tender cervical lymph nodes
• Fever
• Malaise
• sore throat
 Assessment and Diagnostic
Findings

• Rapid screening tests for streptococcal

antigens such as
– the latex agglutination (LA) antigen test
– solid-phase enzyme immunoassays (ELISA)
– optical immunoassay (OIA)
– streptolysin titers
– throat cultures
• Nasal swabs and blood cultures
 Medical Management

• Viral : supportive measures

• Bacterial pharyngitis: antimicrobial
agents.
 PHARMACOLOGIC THERAPY

• bacterial : penicillin is usually the treatment

of choice.
• Allergies to penicillin and resistance :
cephalosporins and macrolides
(clarithromycin and azithromycin)
• 10 days
• Severe sore throats : analgesic medications
 NUTRITIONAL THERAPY

• A liquid or soft diet

• severe situations: IV fluids
• 2 to 3 L per day of fluids
 CHRONIC PHARYNGITIS

• persistent inflammation of the pharynx.

• It is common in adults who work or live
in dusty surroundings, use their voice to
excess, suffer from chronic cough, and
habitually use alcohol and tobacco
• Three types of chronic pharyngitis are
recognized:
– Hypertrophic:
• general thickening and congestion of the pharyngeal mucous
membrane
– Atrophic
• probably a late stage of the first type
• the membrane is thin, whitish, glistening, and at times
wrinkled
– Chronic granular (“clergyman’s sore throat”):
• numerous swollen lymph follicles on the pharyngealwall
 Clinical Manifestations

• constant sense of irritation or fullness in

the throat
• mucus that collects in the throat
– can be expelled by coughing
• difficulty swallowing.
 Medical Management

• Treatment of chronic pharyngitis is

based
– on relieving symptoms
– avoiding exposure to irritants
– correcting any upper respiratory,
pulmonary, or cardiac condition that might
be responsible for a chronic cough.
• Nasal congestion
– Nasal sprays or medications containing ephedrine
sulfate (Kondon’s Nasal) or phenylephrine
hydrochloride (Neo-Synephrine).
• Antihistamine decongestant medications
– Drixoral or Dimetapp, is taken orally every 4 to 6
hours.
• Aspirin or acetaminophen
– antiinflammatory and analgesic properties.
 TONSILLITIS AND
ADENOIDITIS

• Tonsils
– each side of the oropharynx.
– faucial or palatine tonsils and lingual tonsils
• located behind the pillars of fauces and tongue,
– serve as the site of acute infection
(tonsillitis).
• Chronic tonsillitis is less common
• Infection nof the adenoids frequently
accompanies acute tonsillitis.
• Group A beta-streptococcus
– the most common organism associated
with tonsillitis and adenoiditis.
 Clinical Manifestations

• sore throat, fever, snoring,

• and difficulty swallowing.
• Enlarged adenoids may cause
mouthbreathing,
• earache, draining ears, frequent head colds,
bronchitis,
• foul-smelling breath, voice impairment, and
noisy respiration.
Tonsillitis & Adenoiditis - Dx
• Mono
Dx
• Visualize
• C&S
 Medical Management

• Tonsillectomy
– medical treatment is unsuccessful
– there is severe hypertrophy, asymmetry, or
peritonsillar abscess that occludes the pharynx
– swallowing difficult
– endangering the airway (particularly during sleep).
 Indications
• repeated bouts of tonsillitis
• hypertrophy of the tonsils and adenoids that
could cause obstruction and obstructive sleep
apnea;
• repeated attacks of purulent otitis media
• suspected hearing loss due to serous otitis media
• exacerbation of asthma or rheumatic fever.
Tonsillitis & Adenoiditis - Tx
• Kissing tonsil's
• THIS IS NOT TONSILLITIS!
• In this picture taken a week
after tonsillectomy, the
tonsils have been removed
and the whitish discoloration
in the tonsillectomy bed is the
eschar that forms
postoperatively.

• This is normal after a

tonsillectomy and should not
be confused with infection.

• Occasionally, this white

eschar falls off prematurely,
causing delayed
postoperative hemorrhage
 Tonsillitis & Adenoiditis
Post-op care
• Hemorrhaging
– Coffee ground emeses
– Bright red emeses
– Pulse
 
– Temp

– Restlessness
– Tarry stool
  swallowing
 Tonsillitis & Adenoiditis
Post-op
• Position
– Prone/side lying
until…
• Gag returns
– Semi-fowler’s
• Pain control
– Ice collar
– Acetaminophen
• Not aspirin
 Tonsillitis & Adenoiditis
Post-op
• Diet
– Ice cold fluids
– Adv. To normal ASAP
• 2-3 days
– Milk products
 
– Avoid
• Spicy
• Hot
• Acidic
• Rough
 Tonsillitis & Adenoiditis
• Post-op
• Pt education
– S&S of hemorrhaging
– Mouthwash good
– Avoid
• Coughing
• Sneezing
• Vigorous nose blow
• Vigorous gargling
• Rough foods
– Expect black tarry stools
– Normal activity ASAP
 Peritonsillar Abscess
Pathophysiology
• Pus & blood filled
sacs on tonsil
Etiology
• Complication of
strep throat
 Peritonsillar Abscess
S&S
• Pain
– Local
– Radiates  ear
• Dysphagia
– drooling
• Dysphasia
• Fever
• Red throat
 Peritonsillar Abscess
Tx • Ice collar
• Antibiotics
• No smoking
• Incision & drain
– Lanse • Ventilator?
• Warm saline irrigation
• Hydrogen peroxide
• Analgesics
– Topical
– Tylenol
– No aspirin
– ? narcotics
• most common antimicrobial agent: oral
penicillinwhich is taken for 7 days.
• Amoxicillin and erythromycin are
alternatives.
 LARYNGITIS

• inflammation of the larynx,

• Result of voice abuse or exposure to
dust, chemicals, smoke, and other
pollutants, or as part of an upper
respiratory tract infection.
• Most common cause: Virus
• Secondary bacterial infection
• Associated with allergic rhinitis or
pharyngitis
• Associated with exposure to sudden
temperature changes, dietary
deficiencies, malnutrition, and an
immunosuppressed state.
• Laryngitis is common in the winter and
is easily transmitted
 Clinical Manifestations
• hoarseness
• aphonia (complete loss of voice)
• severe cough.
• Chronic laryngitis is marked by
– persistent hoarseness.
• Laryngitis may be a complication of upper
respiratory infections.
 Medical Management

• resting the voice

• avoiding smoking, resting, and inhaling
cool steam or an aerosol.
• appropriate antibacterial therapy
• Chronic laryngitis: treatment includes
– resting the voice
– eliminating any primary respiratory tract
infection
– Eliminating smoking
– avoiding second-hand smoke.
• Topical corticosteroids
– beclomethasone dipropionate (Vanceril)
inhalation, may also be used.
– may reduce local inflammatory reactions.
Chest and Lower Respiratory
Tract Disorders
 Atelectasis

• Collapse or airless condition of the

alveoli caused
byhypoventilation,obstruction of
airway or compression
 Pathophysiology

• reduced alveolar ventilation or any type of

blockage that impedes the passage of air to
and from the alveoli that normally receive air
through the bronchi and network of airways.
• isolated portion of the lung becomes airless
and the alveoli collapse.
 Causes
• altered breathing patterns
• Retained secretions, pain, alterations in small
airway function
• Prolonged supine positioning
• increased abdominal pressure
• reduced lung volumes due to musculoskeletal or
neurologic disorders
• Restrictive defects, and specific surgical
procedures (eg, upper abdominal thoracic, or
open heart surgery).
• Atelectasis may also result from
– excessive pressure on the lung tissue, which
restricts normal lung expansion on
inspiration.
• fluid accumulating within the pleural space
(pleural effusion),
• air in the pleural space (pneumothorax)
• blood in the pleural space (hemothorax).
 Clinical Manifestations

• usually is insidious.
• Signs and symptoms include
– cough
– sputum production
– low-grade fever
– marked respiratory distress (lobar atelectasis)
– dyspnea, tachycardia,
– tachypnea, pleural pain, and central cyanosis
 Assessment and Diagnostic
Findings
• Decreased breath sounds and crackles are heard over
the affected area.
• Chest x-ray: patchy infiltrates or consolidated areas.
• pulse oximetry: (SpO2) low saturation of hemoglobin
with oxygen (less than 90%)
• lower-than-normal partial pressure of arterial oxygen
(PaO2).
 Atelectasis
• Management
1. First line measures :(turning , early
ambulation , lung volume expansion ,
coughing, spirometry ,breathing
exercises
2. If there is no response : (PEEP , IPPB)
3. Bronchoscopy
4. Postural Drainage & percussion
5. If cause is compression remove the
cause
 positive
expiratory pressure or PEP
therapy
 Preventing Atelectasis
• Change patient’s position frequently,
especially from supine to upright position,
to promote ventilation and prevent
secretions from accumulating.
• Encourage early mobilization from bed to
chair followed by early ambulation.
• Encourage appropriate deep breathing
and coughing to mobilize secretions and
prevent them from accumulating.
 Preventing Atelectasis

• Teach/reinforce appropriate technique for incentive

spirometry.
• Administer prescribed opioids and sedatives judiciously
to prevent respiratory depression.
• Perform postural drainage and chest percussion, if
indicated.
• Institute suctioning to remove tracheobronchial
secretions, if indicated.
 Acute Tracheobronchitis
• An inflammation of the mucus
membrane of the trachea & the
bronchial tree , often follow upper
respiratory tract infection
• Inhalation of physical and chemical
irritants, gases, and other air contaminants
can also cause acute bronchial irritatation
 Causes
• Streptococcus pneumoniae
• Haemophilus influenzae
• Mycoplasma pneumoniae
• Fungal infection (eg, Aspergillus
tracheobronchitis)
 Clinical Manifestations

1.Dry irritating cough “expectorate sputum”

2. Sternal soreness from coughing
3. Fever ,stress , night sweating
4. Headache & general malaise
5. As the infection progress the patient
develop (shortness of breath, noisy
breath ,& purulent sputum
 Medical Management

1. Antibiotics depend on symptoms &

culture
2. Expectorant may be prescribed
3. Increase fluid intake
4. Rest & cool therapy
5. Suctioning & Bronchoscopy
 Pneumonia
• An inflammation of the lung tissue that
is caused by microbial agent
• “Pneumonitis” is a more general term
that describes an inflammatory
process in the lung tissue
• caused by various microorganisms,
• including bacteria, mycobacteria,
chlamydiae, mycoplasma,
• fungi, parasites, and viruses.
• Conditions that produce mucus or bronchial
obstruction and interfere with normal lung
drainage (eg, cancer, cigarette smoking,
COPD)
• Immunosuppressed patients and those with a
low neutrophil count (neutropenic)
• Smoking; cigarette smoke disrupts both
mucociliary and macrophage activity
• Prolonged immobility and shallow breathing
pattern
• pneumonia has been categorized into
• one of four categories: bacterial or typical, atypical,
anaerobic/
• cavitary, and opportunistic. However, there is
overlap in the microorganisms
• thought to be responsible for typical and atypical
pneumonias.
• A more widely used classification scheme
categorizes the
• major pneumonias as community-acquired
pneumonia, hospitalacquired
• pneumonia, pneumonia in the
immunocompromised
• host, and aspiration pneumonia
• Community Acquired Pneumonia
(CAP)
1. Occurs either in community setting or within
the first 48 hrs of hospitalization
2. Most common in people younger than 60 yrs
3. Most prevalent during winter & spring
4. Caused by pneumococcus & H influenza
5. Virus the cause in infants & children
 Community-Acquired
Pneumonia

• Streptococcus pneumoniae
• winter months.
• the elderly and in patients with COPD,
heart failure, alcoholism, asplenia,
following influenza
 Hospital Acquired Pneumonia
(HAP)
• the onset of pneumonia symptoms more
than 48 hrs after admission to hospital.
• Also called nosocomial infection
• Common organism E.colli ,Klebsiella
,S.aurious
• It occurs when host defense impaired in
certain conditions
 Pneumonia in the Immuno
compressed host

• Caused by organisms also observed

in CAP,HAP.
• Has subtle onset with progressive
dyspnea , fever , &productive cough
 Pneumonia
• Clinical Manifestations
1. Sudden onset of shaking chills
2. Rapidly increase in body temperature
38-40 C
3. Chest pluratic pain increased by
deep breathing
4. Patient looks severely ill with marked
tachypnea
 Pneumonia
1. Shortness of breath
2. Orthopnea
3. Poor appetite
4. Diaphoresis &tires easily
5. Purulent sputum
 Pneumonia
• Medical Management
1. Appropriate antibiotics depend on
culture result
2. Hydration (increase fluid intake )
3. Antipyretic for fever & Headache
4. Warm moist inhalation to relieve
irritation
1. Antihistamine to relieve sneezing &
rhinorrhea
2. Oxygen & respiratory supportive
measures
• Complications : Shock & respiratory
failure , Atelectasis
& plural effusion
Super infection
• The nurse
• should monitor the following:
• • Changes in temperature and pulse
• • Amount, odor, and color of secretions
• • Frequency and severity of cough
• • Degree of tachypnea or shortness of breath
• • Changes in physical assessment findings (primarily
assessed
• by inspecting and auscultating the chest)
• • Changes in the chest x-ray findings