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Chapter 31
Chronic Respiratory
Disorders
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Learning Objectives
• Identify examples of chronic inflammatory, obstructive,
and restrictive pulmonary diseases.
• Explain the relationship between cigarette smoking and
chronic respiratory disorders.
• For selected chronic respiratory disorders, describe the
pathophysiology, signs and symptoms, complications,
diagnostic measures, and medical treatment.
• Assist in developing a nursing care plan for the patient
who has a chronic respiratory disorder.
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Asthma
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Pathophysiology
• Potentially reversible obstructive airway
disorder: airway inflammation and
hyperresponsiveness
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Pathophysiology: Acute Episode
• Begins when “triggers” activate the inflammatory
process
• Airways constrict and become edematous
• Mucous secretion increases, forming plugs in the
airways, and tenacious sputum is produced
• Obstruction causes air to be trapped in the alveoli,
creating a ventilation-perfusion mismatch
• Effect is hypoxemia with compensatory
hyperventilation
• Acute episodes begin within 30 to 60 minutes after
exposure to trigger and resolve 30 to 90 minutes later
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Figure 31-1
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Pathophysiology
• Late phase
• Begins 5 to 6 hours after the early phase response
• Red and white blood cells infiltrate swollen tissues
of the airways
• During this phase, which lasts several hours or days,
the airways are hyperreactive (very sensitive)
• Risk for another episode until phase subsides
• When no specific trigger can be identified, the
patient may be said to have “intrinsic” asthma
• Asthma with known triggers: “extrinsic” asthma
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Signs and Symptoms
• Dyspnea, productive cough, use of accessory
muscles of respiration, audible expiratory
wheezing, tachycardia, and tachypnea
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Medical Diagnosis
• Health history, the physical examination, and
the pulmonary function test results
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Medical Treatment
• Bronchodilators
• Anti-inflammatory drugs
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Figure 31-2
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Assessment
• Essential information (medications, allergies,
known cardiac disease, sleep disruption);
immediately take steps to relieve symptoms
• Health history
• Frequency and severity of attacks, the factors
known to trigger attacks, effect of condition on
patient’s life, strategies used to manage the
condition, sources of stress and support, and
patient’s knowledge about asthma and its treatment
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Assessment
• Physical examination
• Measurement of vital signs and auscultation of lung
sounds
• Assess skin color and respiratory effort
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Interventions
• Ineffective Breathing Pattern
• Impaired Gas Exchange
• Anxiety
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Chronic Bronchitis and
Emphysema
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Pathophysiology
• Chronic bronchitis
• Bronchial inflammation; increased production of mucus
and chronic cough that persist for at least 3 months of
the year for 2 consecutive years and by impaired ciliary
action
• Cause: inhaled irritants, e.g., cigarette smoke
• Cor pulmonale: right-sided heart failure secondary to
pulmonary disease
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Figure 31-3
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Pathophysiology
• Emphysema
• Degenerative, nonreversible disease:
enlargement of the airways beyond the terminal
bronchioles
• Centrilobular emphysema
• Associated with cigarette smoking; affects mainly the
respiratory bronchioles
• Panlobular emphysema
• Affects the respiratory bronchioles and the alveoli
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Figure 31-4
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Complications
• Respiratory failure
• Factors: infection, air pollution, continued smoking,
left ventricular failure, myocardial infarction,
pulmonary embolism, spontaneous pneumothorax,
and adverse effects of drugs
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Signs and Symptoms
• Chronic bronchitis
• Productive cough, exertional dyspnea, and
wheezing
• Emphysema
• Dyspnea on exertion
• Increased anteroposterior diameter
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Figure 31-5
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Figure 31-6
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Figure 31-7
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Medical Diagnosis
• Patient’s health history and physical
examination
• Pulmonary function tests
• Computed tomography (CT) scan
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Medical Treatment
• Drug therapy
• Goals: improved ventilation and removal of
secretions
• Bronchodilators
• Corticosteroids
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Medical Treatment
• Oxygen therapy
• Initial is usually 1 to 3 L/minute
• Chest physiotherapy
• Exercise
• Nutrition
• Supplementary feedings may be needed
• Good hydration
• Treatment of respiratory failure
• Oxygen therapy, aerosol bronchodilators, chest
physiotherapy, and mechanical ventilation
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Surgical Treatment
• Lung volume reduction surgery (LVRS)
• Up to 30% of hyperinflated lung tissue excised to
improve mechanics of breathing, enabling patient to
breathe more deeply
• Bullectomy (removal of bullae)
• Lung transplantation
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Assessment
• Describe the presenting symptoms—often
dyspnea, cough, chest pain, or a combination
of these
• Obtain a complete medical history
• List of current medications and drug allergies
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Assessment
• Physical examination
• Posture, color, respiratory effort, and use of
accessory muscles of respiration; measure vital
signs
• Hypoxemia: restlessness, confusion, and lethargy
• Inspect neck for distention of veins
• Shape of the thorax for the classic barrel chest
• Auscultate lung fields for diminished breath sounds
• Inspect the nails for clubbing, pallor, or cyanosis
• Inspect and palpate the feet and ankles for edema;
note muscle wasting
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Interventions
•
•
•
•
Impaired Gas Exchange
Ineffective Airway Clearance
Anxiety
Imbalanced Nutrition: Less Than Body
Requirements
• Risk for Infection
• Activity Intolerance
• Decreased Cardiac Output
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Figure 31-8
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Bronchiectasis
• Abnormal dilation/distortion of bronchi and bronchioles;
usually confined to one lung lobe or segment
• Follows recurrent inflammatory conditions, infections,
or obstructions but is sometimes congenital
• Signs: coughing, production of large amounts of
purulent sputum
• Also fever, hemoptysis, nasal stuffiness, sinus drainage,
fatigue, and weakness
• Goals: control symptoms and prevent spread
• Treatment: antibiotic therapy, bronchodilators, chest
physiotherapy, and oxygen therapy
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Cystic Fibrosis
• Hereditary disorder characterized by
dysfunction of the exocrine glands and
production of thick, tenacious mucus
• Cough is the first pulmonary symptom
• Becomes productive of thick, purulent sputum;
obstructs airways
• Results in obstruction of the pancreatic ducts
so that pancreatic enzymes cannot be
delivered to the GI tract
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Cystic Fibrosis
• Stools become bulky and foul smelling
• Lose more salt in sweat than normal; at risk for
salt depletion, especially in hot environments
• Over years, symptoms progress: increased
dyspnea, decreased exercise tolerance, and
weight loss
• Airway obstruction and decreased resistance
to infections lead to chronic bacterial infections,
emphysema, atelectasis, and respiratory failure
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Cystic Fibrosis
• Treatment
• Pancreatic enzyme replacement, chest
physiotherapy, and aerosol and nebulizer
treatments to reduce mucus viscosity
• Infections treated with antibiotics
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Cystic Fibrosis
• Nursing care
• To clear airway: administer prescribed medications,
maintain hydration, and perform chest
physiotherapy
• Prevent infection with medical asepsis and protect
patient from others with infections
• Maintain adequate nutrition: administer pancreatic
enzymes as ordered, allow for rest around
mealtimes, and encourage to consume adequate
nutrients
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Tuberculosis
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Etiology and Risk Factors
• An infection caused by Mycobacterium
tuberculosis, an acid-fast aerobic bacterium
• Spread by droplets from infected people during
coughing, laughing, sneezing, and singing
• Anyone may become infected, but most
healthy people not through brief contact
• At increased risk: elderly, economically
disadvantaged and homeless, substance
abusers, children younger than 5 years, the
immunosuppressed, racial and ethnic groups
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Pathophysiology
• Most people do not acquire active
(symptomatic, progressive) tuberculosis
• Body’s immune response attempts to destroy
the infecting organisms, but some may escape
into the lymph nodes or throughout the body
• The site of the primary infection may undergo
necrotic degeneration
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Pathophysiology
• Cavities develop that are filled with infectious
material, which eventually liquefies and is
coughed up as sputum
• In some, infectious process progresses, and
active tuberculosis develops
• It is possible for inactive bacteria to be reactivated,
causing illness later
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Signs and Symptoms
• Cough, night sweats, chest pain and tightness,
fatigue, anorexia, weight loss, and low-grade
fever
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Medical Diagnosis
• History and physical examination
• Sputum cultures, acid-fast smears of
potentially infected body fluids, tuberculin skin
tests, and chest radiographs
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Medical Treatment
• Common preventive treatment is isoniazid
therapy for 9 to 12 months
• Individuals with inactive tuberculosis may be
treated with INH alone, INH with rifampin, or
rifampin with pyrazinamide
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Assessment
• A complete health history and a physical
examination
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Interventions
•
•
•
•
•
Impaired Gas Exchange
Social Isolation
Risk for Injury
Fatigue
Imbalanced Nutrition: Less Than Body
Requirements
• Ineffective Therapeutic Regimen Management
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Interstitial Lung Disease
• Inflammation of the lower respiratory tract and
thickening and fibrosis of the alveolar walls;
render the alveoli nonfunctional
• May be caused by inhaled substances or
connective tissue disorders; sometimes no
specific cause identified
• Examples: idiopathic pulmonary fibrosis
(occupational lung diseases), sarcoidosis
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Idiopathic Pulmonary Fibrosis
• Pathophysiology
• Formation of scar tissue in lung tissue after
inflammation or irritation
• Cigarette smoking, frequent aspiration, or exposure
to environmental or occupational substances
• Complications
• Pulmonary hypertension, cor pulmonale, and
ventilatory failure
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Idiopathic Pulmonary Fibrosis
• Signs and symptoms
• Nonproductive cough and progressive dyspnea
• Inspirational crackles heard in the lungs on
auscultation
• Clubbing of the fingertips
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Idiopathic Pulmonary Fibrosis
• Medical treatment
• Corticosteroids, bronchodilators, and oxygen
therapy
• Also cytotoxic drugs and antifibrotic agents
• Interventions
• Similar to those described for the patient with COPD
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Occupational Lung Diseases
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Acute Respiratory Irritation
• Inhalation of gases such as ammonia or
chlorine
• Effects usually temporary, but if the lower
airways are affected, pulmonary edema or
alveolar damage and airway obstruction
• May have coughing, wheezing, and dyspnea
• Symptoms resolve within a few days to several
weeks; usually no permanent lung damage
• Treatment: managing symptoms and avoiding
exposure
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Occupational Asthma
• Inhalation of plant or animal proteins; cause an
allergic reaction
• Treatment: same as for bronchial asthma
• Initial acute symptoms last only a few hours,
but patient may have hyperreactive airway for
years
• This means that future exposure to irritants
may trigger acute asthmatic symptoms
• Patient should avoid continued exposure to the
offending substance
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Hypersensitivity Pneumonitis
• Allergic inflammatory response of the alveoli to
inhaled organic particles
• May resolve in a few days, or patient may
contract pulmonary edema or interstitial fibrosis
with permanent restrictive or restrictiveobstructive disease
• Treated with corticosteroids and avoidance of
irritants; respiratory support may be needed if
symptoms are severe
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Pneumoconiosis
• Caused by inhalation of various dusts
• In response to repeated exposure to silica,
asbestos, or coal dust; characterized by diffuse
pulmonary fibrosis and restrictive lung disease
• Aggravated by cigarette smoking; advised to
avoid offending dust and cigarette smoke
• Otherwise, treatment is symptomatic
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Chronic Restrictive
Pulmonary Disorders
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Sarcoidosis
• Pathophysiology
• Inflammatory condition: affects the skin, eyes, lungs,
liver, spleen, bones, salivary glands, joints, and
heart
• An unknown factor triggers a series of immune
processes; leads to formation of clusters of cells
and debris in affected tissues called granulomas
• Signs and symptoms
• Some have no symptoms, others experience dry
cough, dyspnea, chest pain, hemoptysis, fatigue,
weakness, weight loss, and fever
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Sarcoidosis
• Medical diagnosis
• Chest radiography, pulmonary function tests, and
flexible bronchoscopy with transbronchial lung
biopsy
• Medical treatment
• If patient is asymptomatic, no treatment is indicated
• 6- to 12-month course of systemic corticosteroids
• Methotrexate used as an alternative to
corticosteroids
• Lung transplantation only option for patients with
end-stage disease who do not respond to drug
therapy
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Sarcoidosis
• Nursing care
• Monitoring for progressive dysfunction and teaching
about corticosteroid therapy
• Care of the patient with severe pulmonary
symptoms is similar to that for patients with COPD
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Lung Cancer
• Etiology and risk factors
• Leading cause of cancer death in the United States
• Cigarette smoking: leading cause
• Risk increased more for smokers exposed to other
carcinogenic substances, such as arsenic, asbestos,
and radioactive materials
• Evidence that “secondhand” smoke a threat to
nonsmokers
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Lung Cancer
• Pathophysiology
• Small cell (“oat cell”) lung carcinoma (SCLC)
• Non–small cell lung carcinoma (NSCLC)
• Squamous cell carcinomas, adenocarcinomas, large cell
carcinomas, and bronchial carcinoids
• Small cell and large cell undifferentiated carcinomas
grow rapidly: other lung cancers grow slowly
• All can metastasize to other body organs
• SCLCs, which grow rapidly, tend to metastasize
early
• Can invade the pericardium, causing pericardial
effusion and possibly triggering dysrhythmias
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Lung Cancer
• Signs and symptoms
• Persistent cough, hemoptysis, chest pain, and
recurring pneumonia or bronchitis
• May have dyspnea, weight loss, and pain in the
shoulder, arm, or hand
• Other signs and symptoms may be related to
metastatic lesions
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Lung Cancer
• Medical diagnosis
• Radiographic procedures (chest radiography, CT
scan, MRI), fiberoptic bronchoscopy, sputum
cytology studies, and biopsy of tissue obtained
through bronchoscopy, percutaneous transthoracic
fine-needle biopsy, thoracotomy, or other methods
• Radionuclide scans of bones, liver, or brain to detect
metastatic lesions
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Lung Cancer
• Medical treatment
•
•
•
•
Radiotherapy
Chemotherapy
Targeted biologic therapies
Surgical treatment
• Wedge resection, sleeve lobectomy, segmental resection,
lobectomy, or pneumonectomy
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Figure 31-9
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Lung Cancer
• Nursing care
• Nurses must continue to educate the public about
the dangers of cigarette smoking to help eliminate
the primary cause of lung cancer
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Extrapulmonary Disorders
• Chest deformities interfere with lung expansion
• Neuromuscular diseases such as myasthenia
gravis and amyotrophic lateral sclerosis affect
the muscles of respiration
• Head or spinal cord injuries can disrupt the
breathing center in the brain or the neural
control of the diaphragm
• Heart failure with pulmonary edema fills lungs
with fluid, interfering with the exchange of
gases
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Figure 31-10
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