Essentialsof)Human)...

Copyright © 2016 by Elsevier Inc. All rights reserved. 1

Copyright © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Essentials of Human Diseases and Conditions

6th edition

Margaret Schell FrazierJeanette Wist Drzymkowski

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Copyright © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Chapter 9

Diseases and Conditions of the Respiratory System

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Learning Objectives Lesson 9.1: The Respiratory System

and Associated Conditions1. Explain the process of respiration.2. Discuss the causes and medical treatment for (a) the common cold, (b) sinusitis, and (c) pharyngitis.

3. Name the treatment of choice for nasal polyps.

4. Name some systemic disorders that might cause epistaxis.

5. Discuss the prognosis of cancer of the larynx.


6. Define atelectasis and discuss some possible causes.

7. Compare the clinical pictures of (a) a patient with pulmonary embolism and (b) one with pneumonia.

8. List some health hazards of common molds.9. List some possible causes of pulmonary abscess.

Learning Objectives Lesson 9.1: The Respiratory System and Associated Conditions (Cont.)


Orderly Function of the Respiratory System

Respiration made possible by ventilation and healthy lung tissue perfused by blood

Breathing is controlled by central nervous system

Pulmonary circulationØ Pulmonary arteries carry deoxygenated bloodØ Pulmonary capillaries for gas exchangeØ Pulmonary veins return oxygenated blood to heart

Lungs and kidneys maintain pH balance


Respiration

External: Oxygen inhaled from the air is exchanged with carbon dioxide

Internal: The exchange of gases between the blood and tissue cells

Inhaled and exhaled air passes through the respiratory tract

Inspiration: Diaphragm contracts, causing air to be sucked into the lungs

Expiration: Diaphragm relaxes, forcing air out of the lungs


Structure of the Respiratory System

From Patton KT, Thibodeau GA: The human body in health & disease, ed 6, Maryland Heights, MO, 2014, Elsevier.


Inspiration and Expiration


Symptoms of Respiratory Disorders

Include:Ø Chest painØ Dyspnea (difficulty breathing) and shortness of breath

Ø Hemoptysis (spitting up blood)Ø Dysphonia (hoarseness)Ø Chills and low- or high-grade feverØ WheezingØ Fatigue


Common Cold

Can infect the nose and pharynx or larynx and various areas of lungs

Symptoms depend on which virus is responsibleØ Nasal congestion and discharge, sneezing, watering eyes, sore throat, hoarseness of the voice and coughing

Group of minor illnesses that can be caused by almost 200 different viruses


Common Cold (Cont.)

An ordinary cold should clear up in 4 or 5 daysØ Antihistamines help dry up nasal secretions, diminish itchy or watery eyes, and decrease flare from allergic reactions

Ø Decongestants stimulate adrenergic receptors, induce vasoconstriction of blood vessels in the nose, throat, and sinuses

Ø Cough suppressants lessen cough


Sinusitis

Frontal sinuses and the maxillary sinuses are most commonly involvedØ Headache, pain, drainage, and tenderness are symptoms

Caused by viral, fungal, or bacterial infections Treatment

Ø Saline and corticosteroid nasal spraysØ Broad-spectrum antibiotics and decongestantsØ Antihistamines and oral corticosteroids


Sinusitis

From Damjanov I: Pathology for the health-related professions, ed 4, St Louis, 2011, Saunders/Elsevier.


Pharyngitis

Often involves inflammation of the tonsils, uvula, and palate, and sore throat with dryness, a burning sensation, or the sensation of a lump

Most common cause is a viral infection Physical examination usually shows red, swollen mucous membranesØ Using lozenges, mouthwashes, salt water gargles, an ice collar, and antiinflammatory medications may help


Nasopharyngeal Carcinoma

Classic clinical triad of symptoms is neck mass, nasal obstruction with epistaxis, and serous otitis media

People from southern China, areas around the Mediterranean Sea, Southeast Asia, and the Arctic are at risk

Surgery is usually not performed as treatmentØ Treated with radiation therapy with or without adjuvant chemotherapy


Laryngitis

Inflammation of the larynx sometimes interferes with breathing;; main symptom is hoarseness

Caused by viral or bacterial infections, can be chronic or acute

Laryngoscopic examination reveals mildly or highly inflamed mucosa

TreatmentØ Voice rest and bed restØ Liberal fluid intakeØ Use of cough syrup


Deviated Septum

Causes narrowing and obstruction of the air passage

May be of no consequence until aggravated by trauma to the nose

Congenital anomaly is usually the cause Treatment is not usually necessary unless compromise of the air passage is noted

The only possible prevention is avoiding trauma to the nose


Deviated Septum (Cont.)

From Monahan FD, Neighbors M: Medical-surgical nursing: foundations for clinical practice, ed 2, Philadelphia, 1998, Saunders.


Nasal Polyps

Can become large enough to obstruct the airway or affect sense of smell

Polyps are caused by the overproduction of fluid in the cells of the mucous membrane

Surgical removal is the treatment of choice, but steroid injection directly into polyps may help

No specific preventive measures are known


Nasal Polyps (Cont.)

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM,Philadelphia, 2000, Saunders.


Anosmia

Ability to taste liquids and food also is impaired or lost

A chronic condition is the most common cause of anosmia Ø Intranasal swelling accompanying an upper respiratory condition causes temporary anosmia

Treatment is aimed at the causeØ Polyps are removedØ Allergic rhinitis is treated with a series of injections


Epistaxis (Nosebleed)

Bleeding usually occurs from only one nostril with no explanation

Nosebleeds that persist for 10 minutes after constant pressure is applied require immediate emergency care

Common causes of epistaxis are colds and infections

Mild hemorrhage may be controlled by applying constant direct pressure


Tumors of the Larynx

Benign or malignant growths on the larynx Dysphonia is usually the only symptom of a tumor on the larynx

Two types of benign tumors: Papillomas and polypsØ Caused by misuse or overuse of the vocal cords

Benign growths treated with correction of vocal strain and reflux management

If discovered early, malignant tumors may often be treated and cured with radiation


Vocal Cord Polyp


Laryngeal Cancer

Persistent hoarseness tends to occur early in the disease process and is the most common symptomØ Other symptoms may include dysphagia, hemoptysis, chronic cough, referred pain to the ear, and stridor

Major risk factors for development of laryngeal cancer are smoking and alcohol abuse

Quality of life issues are often incorporated into the treatment plan


Hemoptysis

Sputum streaked or spotted with blood can be present with minor infections

Profuse bleeding is present in severe lung infections

Trauma, erosion of a vessel, calcification, or tumors can cause bronchial bleeding, as can inflammatory conditions

Source of bleeding is treated once locatedØ Ligation or surgical removal or repair of the involved vessels is indicated for severe bleeding


Atelectasis

Follows incomplete expansion of lobules or segments of the lung, with partial or complete collapse;; dyspnea is another symptom

Caused by an obstruction in the bronchial treeØ Compression atelectasis results when a tumor exerts pressure on the lung and does not allow air to enter

Antibiotics, analgesics, surgical drainage of pleural effusion for treatment


Atelectasis (Cont.)

From Gould B: Pathophysiology for the health professions, ed 3, Philadelphia, 2006, Saunders.


Pulmonary Embolism

Size and location of the embolism and general physical condition of the patient determine consequences of interruption of blood supply

Most common symptom is sudden onset of dyspnea and chest pain

Emboli also may be composed of air, fat globules, a small piece of tissue, or a cluster of bacteria


Pulmonary Embolism (Cont.)

Lung scans and CT angiography of the chest are used to image the pulmonary blood flow

Echocardiogram is also used to assess pulmonary artery pressure and right heart function

Primary treatment is aimed at preventing a potentially fatal episode and maintaining cardiopulmonary integrity and adequate ventilation and perfusion


Pulmonary Embolism (Cont.)

From Kumar V, Cotran R, Robbins S: Robbins basic pathology, ed 8, Philadelphia, 2008, Saunders.


Pneumonia

The inflammation may be either unilateral or bilateral and involve all or only a portion of an infected lung

Aspiration pneumonia results from aspiration of liquids or other material into the tracheobronchial tree

Pneumonia usually is caused by viral or bacterial infections


Treatment Options for Pneumonia

Include:Ø Organism-specific antibiotics are prescribed for bacterial pneumonia

Ø Penicillin is the drug of choice for a pneumococcal pneumonia

Ø Mycoplasma infections may be treated with broad-spectrum antibiotics

Ø Fungal infections require the use of various antifungal medications, whereas viral infections are treated with specific antiviral agents


Appearance of Pneumonia

From Long BW, Frank ED, Ehrlich RA: Radiography essentials for limited practice, ed 4, St Louis, 2013, Elsevier.


Health Hazards of Common Molds

Toxic mold inside homes can cause allergic symptoms or unique/rare health conditions

CDC information Ø Molds grow naturally in both the indoor and outdoor environments

Ø Mold exposure does not always present a health problem

Ø In most cases, mold can be removed by a thorough cleaning with commercial products

Ø All molds should be treated the same


Pulmonary Abscess

Main symptoms are alternating chills and fever

CausesØ Often a complication of pneumonia caused by bacteria

Ø Aspiration of food, foreign object, bronchial stenosis, or neoplasms

Ø Septic embolism is carried to lung via pulmonary circulation

Treatment of abscess is the use of antibiotics for a fairly long duration


Pulmonary Abscess (Cont.)


Learning Objectives Lesson 9.2: Other Conditions of the Respiratory System

10. Compare Legionnaires’ disease with Pontiac fever.

11. Explain who is at greatest risk for (a) respiratory syncytial virus (RSV) pneumonia and (b) histoplasmosis.

12. List the groups recommended to receive prophylactic use of influenza vaccines.

13. Recall what the acronym COPD stands for.14. Contrast the pathologic course of acute bronchitis with that of chronic bronchitis.


15. Compare the pathology involved in bronchiectasis with that of pulmonary emphysema.

16. Name and describe three causes of pneumoconiosis.

17. Describe the presenting symptoms of pleurisy.18. Explain the difference between pneumothorax and hemothorax.

19. Describe the cause of the instability of the chest wall in a patient with flail chest.

Learning Objectives Lesson 9.2: Other Conditions

of the Respiratory System (Cont.)


20. Discuss contributing factors to, and concern about, the rising prevalence of pulmonary tuberculosis (TB).

21. Describe the clinical course of infectious mononucleosis.

22. Explain the pathologic changes of the lungs in adult respiratory distress syndrome (ARDS).

23. Explain what determines the prognosis of sarcoidosis.




24. Name the leading cause of cancer deaths worldwide for both men and women.

25. Explain the possible health consequences of smoking tobacco.




Legionellosis (Legionnaires’ Disease and Pontiac Fever)

Legionnaires’ disease is more severe;; the milder form is Pontiac fever Ø Legionnaires’ produces severe pneumonia-like symptoms

Ø Symptoms of Pontiac fever include a high fever and muscle aches

Both disorders are caused by L. pneumophila Antibiotic therapy is initiated before diagnosis is made

Pontiac fever usually resolves itself


Respiratory Syncytial Virus (RSV) Pneumonia

RSV causes cold-like symptoms, including nasal congestion, otitis media, and coughing

Respiratory syncytial virus is the causative agent of RSV pneumoniaØ Greatest occurrence of these annual epidemic infections is during the winter months

Antipyretics are prescribed for fever, and antibiotics are given for otitis media

Inhalation of 3% hypertonic saline is used to treat RSV


Histoplasmosis

Many patients with histoplasmosis are asymptomatic at onsetØ As the fungus disseminates, patient reports dyspnea and loss of energy to the point of incapacitation

Histoplasmosis is caused by the fungus H. capsulatum, which is carried by dust and is inhaled

Antifungal drugs itraconazole, fluconazole, and amphotericin B, are used to treat more severe or progressive disease


Influenza

Characterized by inflammation of respiratory tract mucous membranes, a severe protracted cough, fever, headache, and sore throat

Transmission is from person to person by inhalation of the virus in airborne mucus discharge

Known viruses that cause influenza are designated as orthomyxovirus types A, B, and C


Influenza (Cont.)

Acute uncomplicated influenza with recovery is the most frequently encountered

Influenza outbreaks may be sporadic or epidemic

Transmission is from person to person by inhalation of the virus in airborne mucus discharge

Bed rest, increased fluid intake, a light diet, and use of antipyretic and analgesic drugs are helpful


H1N1 (Swine Flu)

Novel influenza A (H1N1) virus is a highly unusual mix of swine, bird, and human flu viruses

Contagious and spread from human to human Can range from mild to severe Symptoms of H1N1 in people are similar to the symptoms of regular human flu

H1N1 susceptible to oseltamivir (Tamiflu) and zanamivir (Relenza)


Chronic Obstructive Pulmonary Disease (COPD)

Describes a condition of slow and irreversible progressive airway obstruction

COPD encompasses:Ø Chronic bronchitisØ BronchiectasisØ AsthmaØ EmphysemaØ Cystic fibrosisØ Pneumoconiosis


Acute and Chronic Bronchitis

Acute: Deep, persistent, productive cough is the main symptom

Chronic: Inflammation persists and becomes worse for at least 3 months of the year for 2 years

Acute bronchitis is part of a general URIØ Begins after a common cold or other viral infections

The same bacteria known to cause pneumonia may be responsible for chronic bronchitis


Treatment of Bronchitis

Because acute bronchitis usually is caused by a viral infection, no specific treatment is prescribed, except measures that will relieve symptoms

Treatment of chronic bronchitis is based on the stage of the diseaseØ Low-flow oxygen therapy may be administered as needed for hypoxemia

Ø Postural drainage and percussion are techniques used to help loosen and expectorate thick mucus


Chronic Obstructive Pulmonary Disease (COPD) (Cont.)

Bronchiectasis: Permanent, irreversible dilation or distortion of one or more bronchi, resulting from destruction of muscular and elastic portions of bronchial walls

Pulmonary emphysema: Chronic obstructive pulmonary disorder characterized by destructive changes in alveolar walls and irreversible enlargement of alveolar air spaces


Bronchiectasis

Usually bilateral and involves the lower lobes of the lungs

Chronic cough producing large quantities of sputum is the main symptom

May be caused by repeated damage to the bronchial wall caused by recurrent airway infections

Antibiotics and bronchodilators are prescribed;; postural drainage is encouraged


Bronchiectasis (Cont.)

From Cotran R, et  al: Robbins pathologic basis of disease, ed 6, Philadelphia, 1999, Saunders.


Pulmonary Emphysema

Pulmonary emphysema interferes with both the breathing process and gas exchange in the lungsØ Alveoli become enlarged, which precipitates destruction of the alveolar walls and damage to the adjacent capillary walls

Long-term cigarette smoking appears to be a contributing factor

Drug therapy: 2-Adrenergic sympathomimetic drugs alone in combination with corticosteroids


Emphysema


Pneumoconiosis

Refers to a number of occupational diseases that cause progressive, chronic inflammation, fibrosis, and infection in the lungs

The onset of symptoms can be insidious, with dyspnea on exertion being the first

Usually takes at least 10 years of continual daily exposure to develop

Anthracosis: Also known as black lung or coal miner’s lung


Pneumoconiosis (Cont.)

From Damjanov I, Linder J: Pathology: a color atlas, St Louis, 1999, Mosby.


Pneumoconiosis (Cont.)

Silicosis: Affects workers who are stone masons or metal grinders or who work in quarries

Treatment is directed toward relieving symptoms and includes:Ø Administration of bronchodilatorsØ Oxygen therapyØ Chest physical therapy to help remove secretionsØ The use of short-term corticosteroid drugs


Pleurisy (Pleuritis)

SymptomsØ Sharp, needle-like pain that increases with inspiration and coughing

Ø May also experience fever, chills, and shallow breathing

Pleurisy is usually secondary to other diseases or infectionsØ Two types: Wet and dry

Antibiotic therapy and analgesics to control the pain may be given


Pleurisy (Pleuritis) (Cont.)


Pneumothorax

Symptoms Ø Severe shortness of breathØ Sudden, sharp chest painØ Falling blood pressure and rapid, weak pulse

Pneumothorax can be spontaneous or traumaticØ Spontaneous pneumothorax occurs when an opening is present on the surface of a lung

Ø Traumatic pneumothorax occurs when the integrity of the pleural cavity is breached


Treatment of Pneumothorax

Patient is more comfortable in a Fowler or a semi-Fowler position and may require oxygen

An occlusive dressing is placed over any sucking wound to seal the portal of entry and to prevent additional air from entering the chest cavity

A thoracostomy is performed to withdraw air from the cavity


Pneumothorax and Hemothorax


Hemothorax

Signs of hemorrhage include pale and clammy skin, a weak and thready pulse, and falling blood pressure

Blood enters the pleural space, which causes the lung to collapse

Treatment: Lung must be reexpanded, usually by thoracostomy with closed drainage to evacuate the blood

The prognosis for a hemothorax is guarded


Flail Chest

The patient with flail chest experiences severe pain and dyspnea and is cyanotic and extremely anxious

Direct trauma to the chest wall that fractures three or more adjacent ribs is the cause of flail chest

First responder emergency care employs measures to stabilize the chest wall until surgical repair is possible


Flail Chest (Cont.)


Pulmonary Tuberculosis (TB)

Acquired by inhaling a dried droplet nucleus that contains the tubercle bacillus

With primary TB, patient is asymptomatic The tubercle bacillus M. tuberculosis causes TB and is spread by droplet nucleiØ As the body’s defense mechanisms respond to the bacterial invasion, antigens are produced, which cause necrosis, followed by fibrosis and calcification of the affected tissue

Treatment dependent on whether TB is latent or active


Tuberculosis (TB)

From Kumar V, Cotran R, Robbins S: Robbins basic pathology, ed 8, Philadelphia, 2008, Saunders.


Infectious Mononucleosis: Epstein-Barr Virus (EBV) Infection

SymptomsØ Lymphadenopathy Ø Fever that typically peaks in afternoonØ Listlessness, malaise, chills, anorexiaØ Sore throat, fever, headache, fatigue, cervical and generalized lymphadenopathy

Mononucleosis is caused by the EBV, a herpesvirus

Acute treatment: Force bed rest and fluid intake


Tonsils Infected by Mononucleosis

From Sigler B: Ear, nose, and throat disorders—Mosby's clinical nursing series, St Louis, 1994, Mosby.


Adult Respiratory Distress Syndrome (ARDS)

SymptomsØ Sudden, severe dyspnea with rapid, shallow respirations

Ø Inspiratory intercostals and suprasternal retractions along with cyanosis or mottled skin

Ø Rales, rhonchi, and wheezes may also be present ARDS is considered secondary to some agent that precipitates increased capillary permeability in the lungs, pulmonary edema, and respiratory failure


Adult Respiratory Distress Syndrome (ARDS) (Cont.)

Alveoli fill within 12 to 48 hours of injury, and then tend to collapse at end of expiration, leaving less pulmonary tissue for gas exchangeØ Low pulmonary compliance, pulmonary hypertension, decreased functional residual capacity, and hypoxemia result

The patient receives supportive care onlyØ Efforts are made to correct the underlying cause of ARDS


Sarcoidosis

Patients may have no complaints or mild to severe symptoms, depending on the site of the lesions and the degree of involvement

The exact cause is not certainØ The disorder is thought to be a malfunction of the immune system or caused by a virus

Sarcoidosis abates spontaneously Corticosteroid therapy, such as prednisone, helps to relieve severe symptoms


Lung Cancer

Leading cause of cancer death worldwide in both men and women, 30% of all cancer deaths

The most common symptom is cough with or without sputum production

Other symptoms may include dyspnea, hemoptysis, chest pain, and weight loss

Two main types by histology: Non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC)

The primary risk factor for development of lung cancer is cigarette smoking


Lung Carcinomas

From Damjanov I: Pathology for the health-related professions, ed 4, St Louis, 2011, Saunders.


Diagnosis and Treatment of Lung Cancer

Many patients are symptomatic at the time of diagnosis, some may be diagnosed following a chest radiograph Ø Testing is also done to look for specific biomarkers that may affect treatment choice, such as gene mutations in epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase

Treatment decisions are based on the type of tumor and the stage of the tumor


Prognosis and Prevention of Lung Cancer

Prognosis for patients with lung cancer is generally poorØ Five-year survival rate for all stages and types of lung cancer combined is 15%

Ø Prevention• Cessation of smoking• Avoidance of exposure to secondhand smoke

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