Download Chapter_046

Assisting in
Pulmonary Medicine
Chapter 46
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
1
Learning Objectives





Define, spell, and pronounce the terms listed
in the vocabulary.
Apply critical thinking skills in performing
patient assessment and care.
Describe the organs of the respiratory
system and their functions.
Explain the process of ventilation.
Employ correct respiratory system
terminology in documentation procedures.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
2
Learning Objectives






Compare and contrast infections and
inflammations of the respiratory system.
Describe the diagnosis and treatment of
tuberculosis.
Summarize the disorders associated with
chronic obstructive pulmonary disease and their
treatments.
Teach a patient how to use a peak flow meter.
Perform a nebulizer treatment.
Detail patient teaching for the use of a
metered-dose inhaler.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
3
Learning Objectives





Describe the cancers associated with the
respiratory system.
Distinguish among common respiratory
system diagnostic procedures.
Perform a volume capacity spirometric test.
Correctly employ a pulse oximeter.
Prepare a patient to collect a sputum sample
for culture.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
4
Respiratory System

The respiratory system



Exchanges oxygen from the atmosphere for carbon
dioxide waste
• External
• Internal
Maintains acid-base balance
Ventilation process controlled by respiratory center
in the CNS and assisted by the costal and
diaphragm muscles
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
5
Preconditions 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
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
6
Upper and Lower Respiratory Tracts


Upper—nose, pharynx, larynx; air filtered by
cilia in nose, warmed by capillaries, and
moistened by mucous membrane; epiglottis
protects opening into larynx; vocal cords
vibrate when air is exhaled to create sound
Lower—trachea, bronchial tubes, lungs,
bronchioles, and alveoli; lined with mucous
tissue and cilia to filter and moisten air
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
7
Lungs



Right—three lobes; greater volume capacity
than left lung
Left—two lobes; longer and narrower
Each lung encased in the double-layered
pleural membrane


visceral and parietal layers
pleural fluid
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
8
Lungs
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
9
Respiration and Circulation



The respiratory and circulatory systems work
together to supply body cells with oxygen and
remove metabolic wastes.
The bronchioles deposit oxygenated air into the
alveoli. Surrounding each alveolus is a network of
pulmonary capillaries filled with waste air.
The oxygenated air moves through the
single-celled walls of the alveoli and through
the single-celled walls of these capillaries. Carbon
dioxide is forced out of the capillaries, into the
alveoli, and then into the bronchioles.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
10
Ventilation



This exchange of gas is referred to as
ventilation.
The movement of oxygen from the atmosphere
into the alveoli is called inspiration.
The movement of the waste gases from the
alveoli back into the atmosphere is called
expiration.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
11
Bronchioles and Alveoli
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
12
Respiratory System Defenses

Upper respiratory tract


Mucus-covered ciliated surfaces
Lower respiratory tract



Sterile
Ever-changing air flow
Functions of the immune system
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
13
Major Diseases of the Respiratory
System


Common symptoms include sneezing,
productive or nonproductive cough, sore throat,
hoarseness, fever, general malaise, altered
breath sounds, and changes in breathing
patterns.
Refer to Table 46-1 to review respiratory
system terms.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
14
Documentation Practice

Michael is taking a patient history for a new patient
who reports the following problems: difficulty
breathing; sometimes she has to sit up to breathe
comfortably; occasionally she coughs up blood and
has excessive nasal drainage. Six months ago she
experienced very rapid breathing and a blue color
to her skin, so she was admitted to the hospital and
diagnosed with blood and fluid around her right
lung, which had become infected, causing her lung
to collapse. Based on what Michael knows about
respiratory system terminology, how should he
document this information?
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
15
Infectious Disease: Upper Respiratory
Tract

Upper respiratory tract infections include:

Common cold—caused by virus and has no cure
 Sinusitis—causes edema and collection of mucus
within the sinus cavity, creating a feeling of
pressure, either nasal congestion or rhinorrhea, and
classic sinus headaches
• Treatment: decongestant, antibiotic, analgesic
 Allergic rhinitis—reaction of nasal mucosa to an
environmental allergen
• Treatment: antihistamines (OTC or Allegra, Zyrtec), nasal
sprays (Flonase or Nasalcrom)
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
16
Infectious Disease: Lower
Respiratory Tract

Lower respiratory tract infections include
pneumonia—inflammation of all or part of the
lungs that is caused by bacteria, viruses,
irritants, or other pathogens

Symptoms—fever, chills, general malaise, cough,
hemoptysis, rales, rhonchi, possible empyema
 Diagnosis—chest x-ray films, elevated WBC if
bacterial
 Treatment—antibiotics if bacterial, palliative if viral
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
17
Types of Pneumonia
From Gould B: Pathophysiology for the health professions, ed 3, St Louis, 2006, Saunders.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
18
Tuberculosis





Serious increase since 1980s
Caused by Mycobacterium tuberculosis bacteria;
develops spores; transmitted via sputum droplets
that are inhaled into a susceptible host
Primary (latent) TB—healthy individual isolates
infection into a tubercle and does not develop
disease, or unhealthy person inhales bacillus and
develops disease
Secondary (active) TB—bacilli in tubercles become
active because of decreased host resistance
Signs and symptoms—productive cough with thick,
blood-tinged mucus
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
19
Signs and Symptoms of Latent TB






Asymptomatic
Not infectious
Positive PPD test result
Positive QuantiFERON-TB Gold blood test
result
Normal chest x-ray studies
Negative sputum culture
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
20
Signs and Symptoms of Active TB




Cough for 3 weeks or longer, chest pain,
hemoptysis, fatigue, weight loss, anorexia,
fever with chills, and night sweats
Infectious (highest risk of infection is with
close family members or associates)
Positive PPD and QuantiFERON-TB Gold
blood tests
Abnormal chest x-ray studies and/or positive
sputum culture
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
21
TB Diagnosis




Diagnosis: positive PPD screening followed by positive
chest x-ray film and sputum culture.
QuantiFERON-TB Gold (QFT) blood test — measures
the response to TB proteins when they are mixed with a
small amount of blood.
Positive PPD does not necessarily indicate active
TB — simply means individual was exposed.
Two-step Mantoux test — PPD is administered and read
in 48 to 72 hours; if result is negative a second Mantoux
is done on the opposite arm from 1 to 3 weeks after the
first test and again read in 48 to 72 hours.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
22
TB Treatment



Treatment: long-term combination drug therapy;
isoniazid (INH) daily for 6 months if PPD is positive
but sputum culture is negative; four-drug regimen
daily for 6 months for active TB; treatment
continues for 3 months beyond negative culture.
Recommended medications – isoniazid, rifampin,
pyrazinamide, and ethambutol
All healthcare workers should have annual PPD or
chest x-ray film if they have a history of positive
PPD; facility may require two-step Mantoux
procedure.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
23
Critical Thinking Application

Dr. Samuelson is the primary care physician
for a nursing home in the area and is
concerned because one of the employees
has had a positive result to a Mantoux test.
What other tests will Dr. Samuelson order to
confirm the diagnosis? If those tests come
back positive, how will the patient be treated?
What about the other employees and
residents of the nursing home?
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
24
Chronic Obstructive Pulmonary
Disease



Chronic obstructive pulmonary disease (COPD) is
a group of diseases with chronic airway
obstruction.
Among these diseases are chronic bronchitis,
bronchiectasis, asthma, pneumoconiosis, and
emphysema. The patient with COPD is unable to
ventilate the lungs freely, resulting in an ineffective
exchange of respiratory gases.
Treatments include bronchodilator and
corticosteroid inhalers, evaluation of peak flow
values, nebulizer treatments, and oxygen.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
25
Asthma





Triggers cause inflammation and bronchospasm.
May be exercise-induced or a chronic problem.
Signs and symptoms—nonproductive cough,
dyspnea, expiratory wheezing, chest tightness,
rhonchi; may also have tachycardia, pallor,
diaphoresis.
Inflammation causes edema and mucous
secretion in the bronchioles, and bronchospasms
cause air to be trapped in lungs.
Spirometry reveals airflow obstruction.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
26
Asthmatic Bronchioles


During an asthma attack, smooth muscles
located in the bronchioles of the lung constrict
and decrease the flow of air in the airways.
The amount of air flow is further decreased by
inflammation or excess mucous secretion.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
27
Management of Asthma

Peak flow measurements either daily or at onset of
attack to assess ability to move air into and out of
lungs.

Measures the peak expiratory flow rate—fastest speed
at which patient can blow air out of lungs after taking in
big breath.
 Patient should take three readings, blowing out as hard
as possible, and the highest value should be recorded.
 Refer to Procedure 46-1
RX: bronchodilator rescue inhalers (Ventolin,
Atrovent, MaxAir); steroid inhalers for
inflammation (Aerobid, Azmacort, Flovent) or oral
Accolate or Singulair.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
28
Peak Flow Meter
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
29
Metered Dose Inhaler Patient
Education






Shake drug canister vigorously and place it into
mouthpiece.
Open mouth and hold inhaler approximately 1 inch
away.
Exhale normally, and while beginning to slowly inhale,
depress the canister, releasing a metered dose of
medication.
Breathe in until lungs are full, hold breath to count of
10, and breathe out normally.
If second dose is prescribed, wait at least 1 minute
between puffs.
Spacer may be used for children or older patients who
have difficulty managing the technique.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
30
Asthma Triggers



Common allergens, including pollen, dust
mites, mold, and pet dander.
Irritants such as smoke, pollution, fumes,
cleaning chemicals, and sprays.
Asthma symptoms can be substantially
reduced by avoiding exposure to known
allergens and respiratory irritants.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
31
Pneumoconioses


Environmental causes of respiratory disease
Consequence of long-term exposure to unsafe
air in the workplace:

Anthracosis – coal mining
Asbestosis – insulation manufacture and
shipbuilding

Silicosis – stonecutting or sandblasting

Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
32
Emphysema






Destruction of alveoli because of overinflation and
difficulty with expiration
Progressive and irreversible
Causes—cigarette smoking, occasionally genetic
predisposition, pollutants, chronic bronchitis or asthma
Signs and symptoms—dyspnea, SOB, wheezing, thick
mucus, fatigue, anorexia, persistent cough, peripheral
cyanosis, clubbing of fingers
DX—PFT shows increased residual volume and
decreased forced expiratory volume
RX—oxygen therapy, nebulizer treatments,
bronchodilators, high-calorie diet, pursed-lip breathing
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
33
Emphysema and Cigarette Smoking


Cigarettes contain many hazardous
substances that damage the lungs when
inhaled, including tar, nicotine, carbon
monoxide, and cyanide.
Long-term exposure to secondhand tobacco
smoke and/or repeated respiratory infections
also can increase a person's risk for chronic
obstructive pulmonary disorder.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
34
Obstructive Sleep Apnea





Muscles in the posterior pharynx relax during sleep.
Trachea narrows or closes with inhalation,
momentarily stopping breathing.
Diagnosis – nocturnal polysomnography – patient is
connected to equipment that monitors pulse rate,
brain activity, breathing patterns, blood-oxygen
levels, and limb movements during sleep.
Complications – chronic daytime fatigue,
hypertension, heart disease, memory problems,
morning headaches, depression, and nocturia.
Treatment: CPAP, dental devices, surgery.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
35
Sleep Apnea

Signs and symptoms

Excessive daytime sleepiness
 Persistent loud, disruptive snoring
 Snoring, choking, or gasping sounds during sleep
 Episodes of breathing cessation during sleep
 Awakening with a dry mouth or sore throat
 Morning headache
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
36
Lung Cancer





The most prevalent neoplasms of the respiratory system are
lung cancer and carcinoma of the larynx.
Lung cancer is the leading cause of cancer-related deaths
for both men and women and is a common site for
secondary tumors from metastasis as well as primary
carcinomas.
Lung is a common site for secondary tumors from
metastasis as well as primary carcinomas.
Bronchogenic carcinoma originates in the epithelial lining of
the bronchioles.
Early symptoms—chronic productive cough, SOB, and
chest tightness masked by symptoms regularly displayed by
habitual smokers.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
37
Lung Cancer
From Damjanov IL: Pathology for the health-related professions, ed 3, Philadelphia, 2006, Saunders.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
38
Pulmonary System Cancer Prognosis



Prognosis is very poor for lung cancer because
early symptoms mimic chronic conditions in
long-term smokers.
Carcinoma of the larynx is linked to smoking
and chronic alcohol consumption.
Most laryngeal tumors are discovered in their
early stages and carry a very good prognosis.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
39
The Medical Assistant’s Role in
Pulmonary Procedures

Assisting with the examination


Have patient disrobe to the waist and don a gown
The medical assistant is responsible for
assisting the physician throughout the
examination, providing the patient privacy and
support, and performing diagnostic tests as
ordered.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
40
Diagnostic Tests

Respiratory system diagnostic procedures

Pulmonary function tests—performed with a spirometer;
used to diagnose a pulmonary abnormality and/or
determine the extent of a pulmonary disease
 Pulse oximetry—a noninvasive method of evaluating the
oxygen saturation of hemoglobin in arterial blood and the
pulse rate
 Cultures—performed on expectorated sputum to identify
infectious pathogens
 Bronchoscopy—viewing the larynx, trachea, and bronchi
with a flexible fiberoptic instrument through which the
physician can collect biopsies or bronchial washings for
cytology or culture
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
41
Critical Thinking Application

Tomas Garcia, a 68-year-old patient, has a
chronic cough, and Dr. Samuelson orders a
sputum culture to rule out an infectious disease.
Mr. Garcia is supposed to collect the specimens
every morning for the next 3 days, but he is very
hard of hearing and does not understand English
very well. His daughter is with him at today’s visit,
and she is bilingual. How should Michael relay
the information about how to collect the sputum
sample? What important details should be
reviewed with Mr. Garcia’s daughter?
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
42
Spirometry


Spirometry is a painless study of air volume
and flow rate within the lungs.
Frequently used to evaluate lung function in
people with obstructive or restrictive lung
diseases such as asthma or cystic fibrosis.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
43
Hand-held Pulse Oximeter
Courtesy Welch Allyn, Skaneateles Falls, N.Y.)
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
44
Bronchoscopy


Technique for viewing the interior of the
airways using sophisticated flexible fiberoptic
instruments; physician explores the trachea,
main stem bronchi, and some of the small
bronchi.
In children this procedure may be used to
remove foreign objects that have been inhaled.
In adults the procedure is most often used to
take samples of suspicious lesions (biopsy)
and for culturing specific areas in the lung.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
45
Bronchoscope



Fiberoptic tube with a tiny camera on the end is
inserted through the nose (or mouth) into the
lungs.
During a bronchoscopic procedure, the scope
passes through the throat into the trachea and
bronchi to provide a view of the
tracheobronchial tree.
The scope also allows the doctor to collect lung
secretions and lung tissue specimens for
biopsy.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
46
Patient Education



The medical assistant can play a vital role in
allaying patient fears by explaining diagnostic
tests, making certain the patient understands
how to prepare for the examination and what
will be expected of him or her during the
procedure.
Provide literature.
Answer questions.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
47