Chapter 19

Pulmonary Disorders

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 Acute Lung Failure
 Description
 Type I—Hypoxemic normocapnic
 Type II—Hypoxemic hypercapnic
 Etiology
 Extrapulmonary
 Intrapulmonary

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 Quick Quiz!
In ALF type I respiratory failure, the patient
presents with:
A. low PaO2 and a normal PaCO2
B. low PaO2 and high PaCO2
C. normal PaO2 and a low PaCO2
D. high PaO2 and a normal PaCO2

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 Acute Lung Failure (Cont.)
 Pathophysiology
 Alveolar
hypoventilation
 Ventilation/perfusion
(V/Q) mismatching
 Intrapulmonary
shunting

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 Acute Lung Failure (Cont.)
 Assessment and diagnosis
 Clinical manifestations
• Hypoxemia
• Hypercapnia
• Acidosis
 Arterial blood gas (ABG) analysis
 Bronchoscopy
 Chest X-ray
 Thoracic ultrasound
 Thoracic CT

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Acute Lung Failure (Cont.)

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 Acute Lung Failure (Cont.)
 Medical management
 Oxygenation  Complications
 Ventilation • Encephalopathy
 Pharmacology • Cardiac
dysrhythmias
 Acidosis
• Venous
 Nutrition support thromboembolism
• Gastrointestinal
bleeding

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 Acute Lung Failure (Cont.)
 Nursing management
 Optimizing oxygenation and ventilation
• Positioning
• Preventing desaturation
• Promoting secretion clearance
 Providing comfort and emotional support
 Maintaining surveillance for complications
 Educating the patient and family

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 Acute Respiratory Distress
Syndrome
 Description
 Definition  Classification
• Timing • Mild
• Chest imaging • Moderate
• Origin of edema • Severe
• Oxygenation  Mortality—34% to
58%

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 Acute Respiratory Distress
Syndrome
 Etiology
 Direct injuries
 Indirect injuries
 Major risk factors
 Sepsis
 Aspiration of gastric contents
 Diffuse pneumonia
 Trauma

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 Acute Respiratory Distress
Syndrome (Cont.)
 Pathophysiology
 Initiated with stimulation of the inflammatory-immune
system
 Exudative phase
 Fibroproliferative phase
 Resolution phase

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 Acute Respiratory Distress
Syndrome (Cont.)
 Assessment and diagnosis
 Symptoms
• Depends on precipitating event
• Associated with phase
 ABG analysis
• Refractory hypoxemia
 Chest X-ray
• “Whiteout” on chest film

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 Acute Respiratory Distress
Syndrome (Cont.)
 Medical management
 Ventilation
• Low tidal volume
• Permissive hypercapnia
• Pressure control ventilation
• Inverse ratio ventilation
• High-frequency oscillatory ventilation

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 Acute Respiratory Distress
Syndrome (Cont.)
 Medical management (Cont.)
 Oxygen therapy
• Positive end-expiratory pressure (PEEP)
 Positive and negative effects
• Extracorporeal and intracorporeal gas exchange
 Tissue perfusion

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 Acute Respiratory Distress
Syndrome (Cont.)
 Nursing management
 Optimizing oxygenation and ventilation
• Positioning—Prone positioning
• Preventing desaturation
• Promoting secretion clearance
 Providing comfort and emotional support
 Maintain surveillance for complications

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 Pneumonia
 Description
 Acute inflammation of the lung caused by an
infectious agent
 Etiology
 Severe community-acquired pneumonia
 Hospital-acquired pneumonia
 Health care–associated pneumonia

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 Quick Quiz!
A patient who develops signs of pneumonia within
24 hours after admission to the hospital is said to
have what type of pneumonia?
A. CAP
B. HCAP
C. HAP
D. VAP

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 Pneumonia (Cont.)
 Pathophysiology
 Aspiration of oropharyngeal organisms
 Inhalation of aerosolized infectious particles
 Migration of organisms from adjacent sites
 Direct inoculation of organisms
 Spread from adjacent structures
 Reactivation of latent infection

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Pneumonia (Cont.)

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 Pneumonia (Cont.)
 Assessment and diagnosis
 Clinical manifestations
• Fever
• Cough
• Shortness of breath
 Chest X-ray
 Sputum culture
 Bronchoscopy
 ABG

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 Pneumonia (Cont.)
 Medical management
 Antibiotic therapy
• Empiric therapy
 Oxygen therapy
 Mechanical ventilation
 Fluid
 Nutritional support
 Independent lung ventilation
• Each lung ventilated separately

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 Pneumonia (Cont.)
 Nursing management
 Optimizing oxygenation and ventilation
• Positioning
• Preventing desaturation
• Promoting secretion clearance
 Preventing the spread of infection
• Hand hygiene
 Providing comfort and emotional support
 Maintaining surveillance for complications

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 Aspiration Pneumonitis
 Description
 Injury due to chemical, mechanical, or bacterial
characteristics of aspirate
 Etiology
 Oropharyngeal bacteria
 Gastric contents
• pH < 2.5
• pH > 2.5

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 Aspiration Pneumonitis (Cont.)
 Pathophysiology
 Acid liquid
 Acid food particles
 Nonacid liquid
 Nonacid food particles

 Assessment and diagnosis

 Gastric contents in oropharynx
 ABGs
 Chest X-ray

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 Aspiration Pneumonitis (Cont.)
 Medical management
 Emergency
• Suctioning
 Follow-up treatment
• Support oxygenation
 Nursing management
 Optimizing oxygenation and ventilation
 Preventing aspiration

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 Pulmonary Embolism
 Description
 Thrombotic embolus
• Deep leg veins
 Nonthrombotic embolus
• Fat
• Tumors
• Amniotic fluid
• Air
• Foreign bodies

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 Pulmonary Embolism
 Etiology
 Predisposing factors
• Hypercoagulability
• Injury to vascular endothelium
• Endothelial injury
 Classification
• Massive PE
• Submassive PE
• Low-risk

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Pulmonary Embolism (Cont.)

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 Pulmonary Embolism (Cont.)
 Pathophysiology
 Increased dead space
 Bronchoconstriction
 Compensatory shunting
 Hemodynamic consequences
• Pulmonary hypertension
• Increased pulmonary vascular resistance
• Right ventricular failure

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 Pulmonary Embolism (Cont.)
 Assessment and diagnosis
 ABG—hypoxemia with respiratory alkalosis
 Abnormal D-dimer
 ECG—sinus tachycardia
 High-probability V/Q scan
 Abnormal pulmonary angiogram
 Abnormal spiral CT

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 Pulmonary Embolism (Cont.)
 Medical management
 Prevention
• VTE prophylaxis
 Treatment
• Promote gas exchange
• Prevent recurrence
• Clot dissolution
 Fibrinolytic therapy
• Reversal of pulmonary hypertension

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 Pulmonary Embolism (Cont.)
 Nursing management
 Prevention of deep vein thrombosis
 Optimizing oxygenation and ventilation
 Monitoring for bleeding
 Providing comfort and emotional support
 Maintain surveillance for complications
 Educating the patient and family

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 Status Asthmaticus
 Description
 Severe asthma attack unresponsive to
bronchodilators
 Etiology
 Upper respiratory infection
 Allergen exposure
 Decrease in anti-inflammatory medications

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 Status Asthmaticus (Cont.)
 Pathophysiology
 Pulmonary effects
• Increased airway resistance
 Cardiovascular effects
 Assessment and diagnosis
 Cough, wheezing, and dyspnea
 Deterioration of pulmonary function tests (PFTs)

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 Status Asthmaticus (Cont.)
 Medical management
 Brochodiolators
 Systemic corticosteroids
 Oxygen therapy
 Intubation and mechanical ventilation

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 Status Asthmaticus (Cont.)
 Nursing management
 Optimizing oxygenation and ventilation
 Providing comfort and emotional support
 Maintaining surveillance for complications
 Educating the patient and family

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 Air Leak Disorders
 Description
 Extra-alveolar air accumulation
 Pneumothorax
 Barotrauma
 Etiology
 Disruption of the parietal or visceral pleura
 Rupture of alveoli

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 Air Leak Disorders (Cont.)
 Pathophysiology
 Pneumothorax
 Barotrauma
 Assessment and
diagnosis
 Chest radiograph
 Subcutaneous
emphysema

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 Air Leak Disorders (Cont.)
 Medical management
 Tension pneumothorax
 Tension
pneumopericardium

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 Air Leak Disorders (Cont.)
 Nursing management
 Optimizing oxygenation and ventilation
 Maintaining the chest tube system
 Providing comfort and emotional support
 Maintaining surveillance for complications

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 Long-Term Mechanical Ventilator
Dependence
 Description
 Assisted ventilation required longer than expected
 Etiology and pathophysiology
 Physiologic factors
 Psychologic factors

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 Long-Term Mechanical Ventilator
Dependence (Cont.)
 Medical and nursing management
 Preweaning stage
• Weaning preparedness
• Weaning readiness
• Weaning approach
• Weaning method

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 Long-Term Mechanical Ventilator
Dependence (Cont.)
 Medical and nursing management (Cont.)
 Weaning process stage
• Weaning initiation
• Weaning progress
• Weaning intolerance
• Facilitative therapies

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 Long-Term Mechanical Ventilator
Dependence (Cont.)
 Medical and nursing management (Cont.)
 Weaning outcome stage
• Weaning completed
• Incomplete weaning

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 Summary
 ALF
 Pulmonary system fails to maintain adequate gas
exchange
 Hallmark of ALF is hypoxemia
 Medical management: treat underlying cause,
promote adequate gas exchange, correct acidosis,
initiate nutrition support, and prevent complications
 Nursing management: optimize oxygenation and
ventilation, comfort and support, monitor for
complications, and educate patient and family

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 Summary (Cont.)
 ARDS
 Noncardiac pulmonary edema and disruption of the
alveolar–capillary membrane
 Hallmark of ARDS is refractory hypoxemia
 Medical management: treat underlying cause,
promote gas exchange, support tissue oxygenation,
and prevent complications
 Nursing management: optimize oxygenation and
ventilation, comfort and support, and monitor for
complications

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 Summary (Cont.)
 Pneumonia
 Acute inflammation of the lung parenchyma
 Medical management: initiate antibiotic therapy,
administer oxygen and mechanical ventilation,
manage fluids and nutrition support, and treat
complications
 Nursing management: optimize oxygenation and
ventilation, prevent spread of infection, provide
comfort and support, and monitor for complications

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 Summary (Cont.)
 Aspiration pneumonitis
 Presence of abnormal toxic substances in the airways
and alveoli resulting in lung injury
 Medical management: clear toxic substance from
airways, support oxygenation, and maintain
hemodynamics
 Nursing management: optimize oxygenation and
ventilation, prevent further aspiration events, provide
comfort and support, and monitor for complications

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 Summary (Cont.)
 PE
 Occurs when a clot or other matter lodges in
pulmonary arterial system, disrupting blood flow to a
region of the lungs
 Medical management: prevent recurrence of PE,
initiate clot dissolution, reverse effects of pulmonary
hypertension, promote gas exchange, and prevent
complications
 Nursing management: optimize oxygenation and
ventilation, monitor bleeding, provide comfort, monitor
complications, and educate patient/family

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 Summary (Cont.)
 Status asthmaticus
 Severe asthma attack that fails to respond to
conventional therapy with bronchodilators; may result
in ALF
 Medical management: support oxygenation and
ventilation
 Nursing management: optimize oxygenation and
ventilation, provide comfort and support, monitor for
complications, and educate patient and family

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 Summary (Cont.)
 Air leak disorders
 Conditions that result in extra-alveolar air
accumulation; classified as pneumothorax or
barotrauma/volutrauma
 Tension pneumothorax and tension
pneumopericardium require emergency intervention
for immediate relief
 Nursing management: optimize oxygenation and
ventilation, maintain chest tube system, provide
comfort and support, and monitor for complications

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 Summary (Cont.)
 Long-term mechanical ventilation dependence
(LTMVD)
 Secondary disorder occurring when patient requires
extended assisted ventilation
 Three stages of weaning: preweaning, weaning
process, and weaning outcome
 Weaning deemed successful when patient breathes
spontaneously for 24 hours without ventilatory
support

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