Respiratory Case Study A – Flashcards

Influenza is caused by an RNA virus that attaches and enters cells in the respiratory mucosa, replicates, and causes inflammation and necrosis of tissues as well as shedding of the virus into the secretions and adjacent cells. The inflammation causes localized congestion and obstruction. Necrosis of respiratory mucosa can lead to greater risk of secondary infection by bacteria. The virus is able to extend into lungs, causing pneumonia.

• Sneezing - a reflex response to irritation in upper respiratory tract to remove irritant. It is caused by foreign material or inflammation in the nasal passages. • Mucociliary escalator - mucous lining the upper and lower respiratory tract traps foreign particles and cilia sweep mucus and debris up and out of respiratory tract. • Coughing - reflex response to irritation caused by nasal discharge dripping into the oropharynx, inflammation of foreign material in the lower respiratory tract, inhalation of irritants (ex - tobacco smoke), or aspiration (food or fluid in lungs). • Alveolar macrophages - remove any foreign material that penetrates to the alveoli in lungs. • Fever - body's immune response to kill and impair growth of infection or virus • Resident flora in Upper respiratory tract • Epiglottis, tonsils

The residents are in close quarters, causing easy transmission. Influenza is easily transmitted directly by respiratory droplets, which can spread up to three meters, or indirectly by contact with contaminated objects, which have not been disinfected by ethanol or detergents. The virus can survive at room temperature up to two weeks. A senior living apartment is also full of residents who are immunocompromised due to older age and other health problems.

• WASH HANDS! Proper hygiene • Alcohol rubs/disinfectants/cleaning supplies • Isolation - have meals brought to room • Anti-viral medication to reduce symptoms and spread if already infected (Tamiflu) • Annual flu vaccination • Face masks for those infected (PPE)

• Appropriate PPE (masks and gloves) • Wash hands/proper hygiene • Flu vaccine • Self-care: Stay home when sick, eating/sleeping well • Standardized protocol for droplet precautions • Peer/resident education

The flu is a VIRAL infection, not bacterial, so antibacterial drugs are ineffective. Misusing antibiotics can be dangerous; they cause the survival and proliferation of drug-resistant strains of bacteria. Antibacterial drugs may be prescribed for secondary infections that are bacterial (ex - bacterial pneumonia).

Mrs. AH is predisposed to develop pneumonia because she is immunocompromised by her current infection with the flu and her old age. The flu causes loss of cilia, respiratory epithelium, and mucociliary escalator function, making it difficult to move inhaled or resident bacteria out of her respiratory system efficiently. Her old age contributes to thinner and more fragile skin and mucosa, fewer capillaries, reduced elasticity of lung tissue, and calcification of costal cartilage (reducing rib mobility - making deep breathing and coughing more difficult). Her living situation, being in close proximity with several other immunocompromised residents, also predisposes her to pneumonia. Medications can also interfere with proper immune system function, causing more risk of pneumonia.

• Physical Exam: o Auscultation - listen for rales (crackling)/rhonchi (rumbling - indicate sputum in airways) o Percuss for "dull thud" in lungs - indicates consolidation/pleural effusion (fluid buildup in space between lungs and pleural) o Respiratory rates - check for tachycardia (body's attempt at compensation for hypoxia - results from pneumococcal pneumonia), check for dyspnea (caused by fluid/exudate in lungs) • Sputum culture tests - culture mucus/sputum from lungs; determine viral vs. bacterial infection; determines what antibiotic to use and how to administer it. o Sputum sample reveals the organism causing infection/infection type o Rusty/dark-colored sputum is a sign of pneumococcal pneumonia. o Yellowish/green cloudy, thick sputum = bacterial pneumonia o Thick, sticky sputum = asthma, cystic fibrosis o Blood-tinged, frothy sputum = pulmonary edema • Blood tests: o WBC count - high levels indicate infection o Blood cultures - can determine specific organism causing pneumonia - not very accurate o Antibody detection - display immune response present towards specific foreign invaders • Chest X-ray - confirms typical distribution of infection; can show pleural abscesses/effusion/the severity of infection; white infiltrates show which lobe is infected (CT scan used if chest x-ray is unclear) • Pulse Oximeter - determines oxygen saturation - checks oxygen levels in blood; low oxygen levels can indicate obstructed gas exchange, improperly functioning lungs. • Blood gas ABG - determine oxygen, carbon dioxide, serum pH and bicarbonate levels - shows if gas exchange in lungs is functioning properly.

• In pneumococcal pneumonia, the bacteria enter the lower respiratory tract, migrate into alveoli, and the bacteria adheres to alveoli. The alveoli become congested with fluid due to inflammation and vascular congestion in the alveolar wall. Exudate fills the alveoli. • The exudate (fluid rich in proteins, neutrophils, RBCs, fibrin, and other cell elements) and bacteria results in consolidation - a solid mass deposited in the lung lobe (lobar pneumonia). Exudate in the alveoli inhibits air flow and gas exchange in the infected lobe. The reduced diffusion of gases causes hypoxia (low ventilation-perfusion ratio), which further causes confusion due lack of oxygen to the brain. • Dehydration, due to fever/decreased thirst and appetite, can also contribute to confusion. • As the alveoli become inflamed, the entire lung lobe is stretched as fluid/exudate/blood in alveolar capillaries fill alveoli (red hepatization), further stretching the pleura, causing friction of the pleural layers and pleuritic pain (pleurisy/pleuritis), especially when breathing in. • The consolidation restricts respiratory expansion, causing pain also. • Hypoxia can also contribute to pain - body compensates for lack of oxygen by hyperventilating, deep breaths stretch inflamed lungs.

• Begins with: Short, painful, dry cough - due to fluid filling the alveoli of lungs after Inflammatory response. • Productive cough - rusty-colored sputum/hemoptysis - due to vascular congestion and red hepatization. • Abrupt high fever with chills/sweats - caused by infection and inflammatory response - fever may be absent in elderly due to decreased immune response • Leukocytosis - high WBC count due to inflammatory response • Dyspnea, tachypnea, tachycardia - body's compensation for hypoxia • Marked fatigue - caused lack of oxygen to blood; dehydration; more difficult breathing because you have less functional lungs • Rales - heard initially over affected lobe, and then disappear as consolidation occurs

Initial: respiratory acidosis due to congestion and hypoventilation: increased Co2, decreased o2, decrease pH. Advanced: metabolic acidosis due to hypoxia and lactic acid buildup. O2 demand is high. Hypoxemia with low ventilation to perfusion ratios. decreased bicarbonate and decreased pH.

Respiratory acidosis: kidneys can conserve bicarbonate and eliminate hydrogen ions into acidic urine Metabolic acidosis: hyperventilate: rapid and deep breathing to blow off CO2.

• Insensible Losses: o High fever (if present) - excessive sweating w/ Na+ and H2O losses o Hyperventilation • Age o Lack fluid reserves o Lack ability conserve fluid quickly o Insufficient water intake prior to illness • Inadequate fluid intake due to o Fatigue

• Hypovolemic: Viscous blood and low blood volume à straining the heart and affecting the brain and kidneys. • Accompanied by more severe electrolyte imbalance • Dehydration won't allow her to compensate properly (kidneys can't excrete as well, and blood can't deliver oxygen as well)

o Antibiotics (ex: penicillin) o Administer analgesics (pain-killers) and anti-cough medications o Adequate hydration - liquefy thick secretions, make them easier to cough up o Teach coughing and deep breathing techniques - improve clearance of airways; suction/nebulizing medications - liquefy secretions, make them easier to cough up o Oxygen therapy - monitor O2 saturation; mechanically support breathing and oxygenation o Reduce fever/promote rest - slows metabolism o Elevate the head of the bed - gravity will expand lungs and provide more surface area for gas exchange o Monitor vitals and ABGs o Provide IV fluids if unable to maintain proper hydration. o Pneumococcal vaccine - recommended particularly for elderly and those at risk because of other disease.