Respiratory disorders

2. INTRODUCTION
• Pleural effusion, a collection of fluid in the pleural space, is rarely a primary
disease process but is usually secondary to other diseases
• The pleural space normally contains only about 10-20 ml of serous fluid.
• Pleural fluid normally seeps continually into the pleural space from the
capillaries lining the parietal pleura and is reabsorbed by the visceral pleural
capillaries and lymphatic system
• Any condition that interferes with either secretion or drainage of this fluid
leads to pleural effusion

3. DEFINITION
Pleural effusion is a collection
of abnormal amount of fluid in
the pleural space.

4. CLASSIFICATION
• Transudative effusions
• Exsudative effusions

5. Transudative effusions
Transudative effusions also known as hydrothoraces, occur primarily in
noninflammatory conditions; is an accumulation of low-protein fluid.
CAUSES
• Increase hydrostatic pressure found in heart failure (most common
cause of pleural effusion)
• Decrease oncotic pressure found in cirrhosis of liver or renal disease.

6. Exudative effusions
• Exudative effusions occur in an area of inflammation; is an
accumulation of high-protein fluid.
• An exudative effusion results from increased capillary permeability
characteristic of inflammatory reaction.
• This types of effusion occurs secondary to conditions such as
pulmonary malignancies, pulmonary infections and pulmonary
embolization.

7. PATHOPHYSIOLOGY
Transudative pleural effusions:
hydrostatic pressure,  oncotic pressure
Unable to remain the fluid with in a intravascular space
Fluid shift interstitial space
Effusion

8. CONT..
Exudative effusions
Invasion of microbes
Initiation of inflammatory reaction
Vasodilation increase capillary permeability
decrease oncotic pressure leak of plasma protein
fluid shift into interstitial space Effusion

9. CLINICAL MANIFESTATIONS
• When a small to moderate pleural effusion is present, dyspnea may be
absent or only minimal.
• Malignant effusion may result in dyspnea and coughing
• Pleuritic chest pain, fever, chills
• Dullness or flatness to percussion
• Decreased or absent breath sounds

10. DIAGNOSTIC EVALUATION
• Chest X-ray or ultrasound detects presence of fluid.
• Thoracentesis, biochemical, bacteriologic, and cytologic studies of
pleural fluid indicates cause.

11. MANAGEMENT
The objectives of treatment are
• to discover the underlying cause,
• to prevent reaccumulation of fluid and
• to relieve discomfort, dyspnea, and respiratory compromise

12. CONT..
General effusion
• Treatment is aimed at underlying cause (heart disease, infection).
• Thoracentesis is done to remove fluid, collect a specimen, and relieve
dyspnea
For Malignant Effusions
• Chest tube drainage or pleurodesis
• Radiation
• Chemotherapy
• Surgical pleurectomy
• Pleuroperitoneal shunt

14. NURSING MANAGEMENT
Nursing Assessment
• Obtain history of previous pulmonary condition
• Assess patient for dyspnea and tachypnea
• Auscultate and percuss lungs for abnormalities
Nursing Diagnosis
Ineffective Breathing Pattern related to collection of fluid in pleural
space as evidenced by dyspnea.

15. CONT..
Nursing Interventions
• Observe patient's breathing pattern, oxygen saturation
• Administer oxygen as indicated by dyspnea and hypoxemia.
• Assist with thoracentesis if indicated
• Maintain chest drainage as needed
• Provide care after pleurodesis.
• Administer prescribed analgesic.

16. COMPLICATION
Large effusion could lead to respiratory failure.

17. PULMONARY EMBOLISM

18. DEFINITION
Pulmonary embolism (PE) refers to the
obstruction of the pulmonary artery or one of
its branches by a thrombus (or thrombi) that
originates somewhere in the venous system
or in the right side of the heart.

19. CAUSES
• Thrombus: Deep vein thrombosis, a related condition, refers to thrombus
formation in the deep veins, usually in the calf or thigh.
• Embolism: there are several types of emboli: fat, air, amniotic fluid, and
septic.
• Trauma
• Surgery: Venous Stasis , Prolonged immobilization
• Foreign bodies (IV/central venous catheters)
• Hypercoagulability: due to release of tissue thromboplastin after
injury/surgery
• Heart failure
• Pregnancy, Oral contraceptive use
• Older than 50 years
• Atrial fibrillation

20. PATHOPHYSIOLOGY
• When a thrombus completely or partially obstructs a pulmonary
artery or its branches.
• the alveolar dead space is increased. The area, although continuing
to be ventilated, receives little or no blood flow (V:Q mismatch). Thus,
gas exchange is impaired or absent in this area
• In addition, various substances are released from the clot and
surrounding area, causing regional blood vessels and bronchioles to
constrict.
• This causes an increase in pulmonary vascular resistance.

22. CONT..
• This results in an increase in pulmonary arterial pressure and, in
turn, an increase in right ventricular work to maintain pulmonary
blood flow.
• When the work requirements of the right ventricle exceed its capacity,
right ventricular failure occurs, leading to a decrease in cardiac
output followed by a decrease in systemic blood pressure and the
development of shock.

23. CLINICAL MANIFESTATIONS
• Dyspnea, tachypnea (very rapid respiratory rate) is the most frequent
sign . The duration and intensity of the dyspnea depend on the extent
of embolization.
• Chest pain is common and is usually sudden and pleuritic.
• Other symptoms include anxiety, fever, tachycardia, cough,
diaphoresis, hemoptysis, and syncope.

24. DIAGNOSTIC FINDINGS
Death from PE commonly occurs within one hour after the onset of
symptoms; therefore, early recognition and diagnosis are priorities.
• Ventilation–perfusion scan
• Pulmonary angiography
• Chest x-ray
• ECG
• Peripheral vascular studies, and arterial blood gas analysis.
• Doppler ultrasonography and venography

25. MEDICAL MANAGEMENT
• General measures to improve respiratory and vascular status
• Anticoagulation therapy
• Thrombolytic therapy
• Surgical intervention

26. General management
• Oxygen therapy is administered to correct the hypoxemia.
• Using elastic compression stockings or leg compression devices
reduces venous stasis.
• Elevating the leg (above the level of the heart) also increases venous
flow.
• Active leg exercises to prevent deep venous thrombosis

27. Anticoagulation Therapy
• Anticoagulant therapy (heparin, warfarin sodium) has traditionally
been the primary method for managing acute deep vein thrombosis
and PE.
• Heparin is used to prevent recurrence of emboli but has no effect on
emboli that are already present.
• Heparin is administered as an intravenous bolus of 5,000 to 10,000
units, followed by a continuous infusion initiated at a dose of 18 U/kg
per hour, not to exceed 1,600 U/hour

28. Thrombolytic therapy
• It resolves the thrombi or emboli more quickly
• Restores normal hemodynamic functioning of the pulmonary
circulation,
• Reducing pulmonary hypertension
• Improving perfusion, oxygenation and cardiac output.
• Thrombolytic therapy (urokinase, streptokinase) may be used in
treating PE, particularly in patients who are severely compromised
(e.g., those who are hypotensive and have significant hypoxemia
despite oxygen supplementation).

29. Surgical management
• Pulmonary embolectomy requires a thoracotomy with
cardiopulmonary bypass technique.
• Transvenous catheter embolectomy is a technique in which a
vacuum-cupped catheter is introduced trans venously into the affected
pulmonary artery. Suction is applied to the end of the embolus and the
embolus is aspirated into the cup.

31. Nursing Management
Nursing Assessment
• All patients are evaluated for risk factors for thrombus formation and
pulmonary embolus.
• Health history: To determine any previous cardiovascular disease.
• Family history: History of any cardiovascular disease in the family may
predispose the patient to PE.
• Medication record: There are certain medications that can increase the
risk for PE.
• Physical exam: Extremities are evaluated for warmth, redness, and
inflammation.

32. Nursing Management
Nursing Diagnosis
• Ineffective peripheral tissue perfusion related to obstructed pulmonary
artery.
• Risk for shock related to increased workload of the right ventricle.
• Acute pain related to pleuritic origin.

33. Nursing Management
Goal and planning
• Increase perfusion
• Display hemodynamic stability.
• Report pain is relieved or controlled.
• Follow prescribed pharmacologic regimen.
• Verbalize understanding of condition, therapy regimen, and medication
side effects.

34. Nursing Management
Nursing Interventions
• Prevent venous stasis: Encourage ambulation and active and passive leg
exercises.
• Monitor thrombolytic therapy: Evaluating INR or PTT report.
• Manage pain: Turn patient frequently and reposition to improve
ventilation-perfusion ratio.
• Manage oxygen therapy: Assess for signs of hypoxemia and monitor the
pulse oximetry values.
• Relieve anxiety: Encourage the patient to talk about any fears or
concerns related to this frightening episode.

35. COMPLICATIONS
• Cardiogenic shock: The cardiopulmonary system is endangered in a
massive PE.
• Right ventricular failure: A sudden increase in pulmonary resistance
increases the work of the right ventricle.

37. DEFINITION
Lung abscess is a pus containing lesion of the
lung parenchyma that gives to a cavity. The
cavity is formed by necrosis of the lung tissue.

38. RISK FACTORS/CAUSES
• Most lung abscess are caused by aspiration of material from the GI tract
into the lungs.
• Risk factors for aspiration include—
• Alcoholism.
• Seizure disorder.
• Neuromuscular disorders.
• Drug overdose.
• General anesthesia.
• Stroke

39. CONT..
• Infectious agents generally cause lung abscesses. Examples: gram
negative organisms (Klebsiella, S. aureus) and anaerobic bacilli.
• Malignant growth.
• TB
• Various parasitic and fungal disease of the lung.

40. CLINICAL MANIFESTATION
• Cough with purulent sputum
• Hemoptysis
• Fever
• Chills
• Pleuritic chest pain
• Dyspnea
• Weight loss

41. CONT..
On physical examination :
• Dullness to percussion.
• Decreased breath sounds on auscultation over the segment of lung
involved.
• Crackles

42. DIAGNOSTIC EVALUATIONS
• History Collection
• Physical examination
• CT Scan
• MRI
• Chest X-ray
• Sputum culture
• Pleural fluid and blood culture
• Bronchoscopy

43. MEDICAL MANAGEMENT
• Antibiotics given for a prolonged period ( up to 2-4 months) are
usually the primary method of treatment.
• Penicillin has historically been the drug of choice because of the
frequent presence of anaerobic organisms.
• According to the recent studies Clindamycin has been shown to be
superior to penicillin, and is the standard treatment for anaerobic lung
infection.

44. SURGICAL MANAGEMENT
• Drainage: when the abscess is 6 centimeters or more in diameter.
Doctor will use a CT scan to guide him as he inserts the drain through
the chest wall into the abscess.
• Surgery: It's rare, but some people need surgery to remove the part of
the lung (segmentectomy) with the abscess. Sometimes the entire lung
has to come out (pneumonectomy) to get rid of the infection.

45. NURSING MANAGEMENT
• Ineffective breathing pattern related to decreased lung expansion as
evidenced by dyspnea.
• Impaired gas exchange related to capillary membrane changes as
evidenced by cyanosis, shortness of breath.
• Activity intolerance related to hypoxemia as evidenced by gasping.
• Imbalance nutrition less than body requirement related to less intake
of food as evidenced by weight loss

46. COMPLICATIONS
• Chronic abscess: That’s lasts for more than 6 weeks.
• Empyema: This is when an abscess breaks into the space between the
lungs and chest wall and fills the space with pus.
• Bleeding: It's rare, but sometimes an abscess can destroy a blood
vessel and cause serious bleeding.
• Broncho-pleural fistula: This is an opening between the tubes of
lungs and layers that cover them.

47. PATIENT EDUCATION
• The patient must be aware of the importance of continuing the
medication for the prescribed period.
• The patient must know about the side effects that need to be informed
to the health care members.
• Sometimes patients are asked to come for routine check ups.
• The patient should be taught how to cough effectively, and how chest
physiotherapy and postural drainage are helpful in their disease
process.
• Rest, good nutrition and adequate fluid intake are all supportive
measures to facilitate recovery.

49. DEFINITION
Pneumothorax is an abnormal collection
of air or gas in the pleural space
separating the lung from the chest wall
which may interfere with normal
breathing, causing the lungs to collapse.

50. TYPES
1. Spontaneous pneumothorax
2. Traumatic pneumothorax
3. Tension pneumothorax

51. Spontaneous pneumothorax
1. Primary: It occurs in young healthy
individuals without underlying lung disease.
It is due to the rupture of apical subpleural
bleb.
2. Secondary: occurs in the presence of pre-
existing lung pathology. Ex : Cystic fibrosis,
COPD, Asthma, pneumonia, Lung cancer.

52. Traumatic pneumothorax
1. Open: Chest wall is damaged by any wound, outside air enters
pleural space and causes lungs to collapse. Usually associated with
hemothorax. E.g. Penetrating trauma: stab wound or gun shot injury.
2. Closed: nonpenetrating chest trauma such as rib fracture can
lacerates the lung or a ruptured bronchus cause air to leaks into
pleural space.
3. Iatrogenic: Postoperative Mechanical ventilation, Thoracocentesis
& Central venous cannulation.

53. Tension pneumothorax
• It is life threatening condition. The pleural pressure is more than the
atmospheric pressure.
• It occurs when site of air leak acts as one way valve, air enters pleural
space during inspiration but cannot escape during expiration.
• Volume of air and intrapleural pressure increasingly elevated results in
compression of lung on the affected side.
• Mediastinal shift towards the unaffected side, compressing the good
lung which further compromises oxygenation.

54. Cont..
• Possible shift of trachea, pressure on the heart and great vessels,
resulting in decreased venous return and cardiac output.
• Associated with clinical manifestations of circulatory collapse
(tachycardia, hypotension & sweating).
• It is more common with Positive pressure ventilation & Traumatic
pneumothorax.

56. RISK FACTORS
• Sex : men are far more likely to have a pneumothorax than are women.
• Smoking.
• Age: The type of pneumothorax caused by ruptured air blisters is most
likely to occur in people between 20 and 40 years old, especially if the
person is very tall & underweight man.
• Genetics.
• Lung disease
• Mechanical ventilation.
• A history of pneumothorax.

57. PATHOPHYSIOLOGY
• In normal people, the pressure in pleural space is negative during the
entire respiratory cycle.
• Two opposite forces result in negative pressure in pleural space (outward
pull of the chest wall and elastic recoil of the lung).
• The negative pressure will be disappeared if any communication
develops between an alveolus or other intrapulmonary air space and
pleural space.
• Air will flow into the pleural space until there is no longer a pressure
difference or the communication is sealed.

59. CLINICAL FEATURES
• Predominant symptom is acute pleuritic chest pain
• Dyspnea results form pulmonary compression
• Breath sounds may be diminished on the affected side
• Percussion of the chest may be perceived as hyperresonant.
• Other signs include: Tachypnoea, Hypoxemia, Cyanosis, Hypercapnia.

60. Presentation of pneumothorax
P-THORAX
• Pleuritic pain
• Tracheal deviation
• Hyperresonance
• Onset sudden
• Reduced breath sounds (and dyspnea)
• Absent fremitus
• X-ray shows collapse

61. DIAGNOSTIC EVALUATIONS
• History Collection
• Physical examination
• CT Scan: to identify underlying lung lesions.
• Chest X-ray: The characteristics of pneumothorax (Pleural line, lung
markings)
• Chest ultrasound

62. TREATMENT
Goals
• To promote lung expansion.
• To eliminate the pathogenesis.
• To decrease pneumothorax recurrence.
Treatment options :
• Simple aspiration
• Intercostal tube drainage
• Trocar tube thoracostomy
• Surgical treatment: pleurodesis, pneumonectomy

63. Simple aspiration
• The aspiration can be done by needle or
catheter
• A volume of < 2.5 L has been aspirated
on the first attempt
• Repeated aspiration is reasonable for
primary pneumothorax when the first
aspiration has been unsuccessful.

64. Trocar tube thoracostomy
• Insertion of trocar into the pleural space.
• Insertion of the chest tube through the trocar

65. Intercostal tube drainage
• A common site of chest tube insertion is in
the 2nd ICS in midclavicular line.
• An alternative site now commonly used is
midaxillary line of 4th and 5th intercostal
space for cosmetic reason and also for
when pleural effusion.

66. Observation of drainage
• No bubble released
oThe lung re-expansion
oThe chest tube is obstructed by secretion or blood clot
oThe chest tube shift to chest wall, the hole of the chest tube is located
in the chest wall.
• If the lung re expanded, removing the chest tube 24 hours after re
expansion. Otherwise, the chest tube will be inserted again or regulated
the position

67. NURSING MANAGEMENT
• Ineffective breathing pattern
• Impaired tissue perfusion
• Risk for infection
• Activity intolerance
• Anxiety
• Imbalanced nutrition
• Knowledge deficit

68. THANK YOU