lower resp tract assessment and diagnostics

# of packs per day x # years smoking

e.g. person smokes a pack a day for 20 years= 20 pack-year smoker

• 1) ACE inhibitors (-prils, pt. may present w/ non-productive, dry cough)
• 2) OTC syrups or inhalers
• 3) bleomycin
• 4) amiodarone (known to induce pulmonary fibrosis)

cough

• Alvoeoli: decr. surface area, diffusion capacity and elastic recoil and alveolar ducts dilate
• Broncioles: ducts dilate
• Ability to cough decreases and airway closes early

Interventions: encourage pulmonary and oral hygiene, upright position, fluids

• Resiual volume: increases (amount of "dead space" a little bit =good but too much = bad)
• Vital capacity and efficiency decr. (amount of air that can be moved out of the lungs after normal insp. and exper....a decr. vital capacity = decr. efficency of gas exchange)
• Interventions: teach exercise importance and assss breathing pattern

Assess for subtle sx of hypoxia...in young pt's = restlessness, in old pt's = confusion

IgA is an antibody produced by lung tissue that is decr. in elderly, so they are at incr. r/f infection. Teach pt to get flu and pneumovac vaccines and exercise, pulmonary hygiene

AP diameter increases, approaches a 1:1 ratio (normal ratio= 1:2 or 5:7). Thorax becomes shorter, progressive kyphoscoliosis (curving of the spine) can be seen, chest wall compliance decr., mobility may decr., osteoporosis is possible...discuss adequate Ca intake, esp. for pre-menopausal women

upon inspection during assessment look at the AP diameter compared to the lateral (side-to-side) diameter. Ratio is normally 1:2, but incr. in pt's w/ emphysema (which results in the typical barrelchest appearance)

Vocal/tactile fremitus is a vibration of the chest wall produced when the pt. speaks, you can feel it upon palpation. It is decr. w/ pneumothorax or pleural effusion, and incr. w/ pneumonia and abscesses bc soud travels/vibrates better through solid

crepitus is air trapped in tissues (air in pleural space has leaked into sub-q) as w/ a pneumothorax and COPD...caution that the air can push on vessels and cause hemodynamic problems

renosance

hyperrenosance = the presence of trapped air, so it may indicate emphysema, asthma, pneumothorax

massive pleural effusion

Dullness= atelectasis or consolidation (ex. of a dull sound can be heard over kidneys/liver)

Tympany can indicate a large pneumothorax

harsh, high-pitched, heard over trachea, I<E

• loud, high-pitched, heard next to trachea, E>I
• If heard on periphery may indicate atelectasis, tumor or pneumonia bc they are transmitted form an area of incr. density

• medium loudness, med. pitch, heard at the sternal boarder and between scapula, I=E
• May indicate normal aging or an abnormaility such as pulmonary consolidation or chronica airway disease

Vesicular BS are NORMAL BS heard in the remainder of the lungs (in the periphery), they are soft, and low-pitched, I>E

have pt. hold breath, if you can still hear the friction rub= pericardial (both sound like sandpaper rubbing together =inflammation)

• Air thru fluid:
• fine: usually heard late in inspiratory phase, can usually clear up w/ coughing, usually only affects small airway
• coarse: louder, more red flag!, may be affecting large airway also, can indicate pneumonia or CHF or other probs

Have pt. say "99"...while listening w/ stethoscope you shouldn't hear it clearly, if you do indicates consolidation

Have pt. whisper "1-2-3"...shouldn't hear clearly

Have pt. say "E"...if it sounds like "A" or "Eh" = consolidation

Skin tests test for allergic rxn (delayed hypersensitivity or type 4 rxn) as evidence of exposure to tuberculosis bacillus, viruses or fungi

exposure to the antigen ...it does not mean the disease is currently present

neg= either there has been no exposure or there is depression of cell-mediated immunity d/t HIV or other active infection...(a pt. w/ decr. immunity may not react to skin test and show pos. result because they are so immunosuppressed)

• 1) make sure injection is intradermal, look for bleb
• 2) mark sites w/ circles and instruct pt. not to wash off, draw diagram and label
• 3) read using good light and look for induration (hardness) not redness

• -0.1 ml of Pruified Protein Derivative (PPD) injected intradermally in forearm
• -area of induration measuring 10 mm or greater in diameter 48-72 hr after injection indicates TB exposure
• -area of 5mm or greater is considered positive in pt's w/ HIV infection

exposure to TB or presence of inactive (dormant disease)

• it does not rule out TB in very old or immunocompromised....
• Anergy= failure to have a skin response bc of reduced immune function when infection is present

• W/ the first TB test we may "wake up the disease" but it doesn't show induration (a pos reading) but if we do a 2nd test it's more definitive (but still not 100%)
• The 2nd test can be done 1wk to 1year after the first.

• -diagnose pulmonary dx progression
• -evaulate disablity and determine the effect of occupation on lung function
• -serial testing can be used as a guide for tx...evaulate response to bronchodilators (and other tx)...should we change, continue, or discontinue current therapy?
• -to determine the need for ventilatory support or readiness to be weaned from ventilator
• -often done pre-op in pt's w/ COPD to see if they need to be on a vent after surgery
• -to screen pt's for lung dx even before the onset of sx
• -to determine the cause of dyspnea:
• -when performed when pt. exercises, PFT's help differentiate lung dx from caridac dysfunction or muscle weakness

• -spirometer used at bedside or in diagnostic department. Client breaths through mouth only and a nose clip may be used . Verbally coach pt to make sure they exhale as much as possible
• -advise client not to smoke 6-8hr before test
• -according to reason for test hold bronchodilators for 4-6 before PFT (hold if you want to see if pt ready to stop meds, give if you want to assess pt's response to meds)
• -monitor for dyspnea, bronchospasm and fatigue after test

FVC= max amount of air that can be exhaled as quickly as possible after max inhalation (breathe in as much as you can then breathe out fast as you can)

FVC indicates respiratory muscle strength and ventilatory reserve. FVC reduced in obstructive dx (bc of air trapping) and in restrictive disease)

FEV1 records the max amount of air that can be exhaled in the first second of expiration

FEV1 is effort dependant and declines normally w/ age. It is reduced in certain obstructive and restrictive disorders

-commonly done at bedside w/ peek flow meter to monitor pt's response to meds

FRC is the amount of air remaining in the lungs after normal expiration. FRC requires the use of helium dilution, nitrogen washout, or body plethymography technique

FRC indicates hyperinflation or air trapping so it's increaesd in obstructive pulmonary disease and decreased or normal in restrictive pulmonary disease

TLC = the amount in the lungs at the end of maximum inhalation

• Increased in obstructive disease d/t air trapping
• Decreased in restrictive disease

• RV= the amount of air remaining in the lungs at the end of a full, forced exhalation
• RV is increased in obstructive pulmonary disease such as emphysema (air trapping)

• -to assess airway anatomy for tumors (cancer staging or culture for infection can be done w/ brush or needle bx), obstruction and atelectasis
• -to remove thick secretions, mucous plugs, or foregin bodies

a flexible fiberoptic bronchoscope is inserted through the mouth, nose, ET tube or trach. May be performed under low-dose sedation

• -NPO prior to the test (usually 4-8 before)
• -informed consent signed
• -assess allergies to iodine, local anesthetic or premeds (atropine to dry secretions and valium to relax)
• -place pulse ox
• -remove dentures
• -monitor VS q15 until stable
• -monitor for hemoptysis
• -NPO until gag reflex returns (gently insert tongue blade and have pt. say ahh. they should gag
• -discourage smoking, talking, couhging for several hrs

• -Aspiration of air or pleural fluid from the pleural space for diagnosis or tx purposes
• -pleural fluid may be drained to releive pulmonary compression and resultant resp. distress caused by cancer, pleurisy, TB, CHF...
• -often followed by pleural bx to further assess
• -can also do pleurodesis- instill meds such as AB or chemo into pleural space

• -informed consent
• -check for allergies to betadine and anesthetic
• -position pt. appropriately and instruct to avoid coughing, deep breathing or sudden movement
• -tell pt. to expect a stinging sensation weh the local anesthetic and pressure when needle (trocher) is inserted

• -may be performed at bedside or under ultrasound or CT guidance
• -HCP's wear goggles/mask
• -18-25G needle insertede into pleural space and attached to a syringe, vaccum collection bottle may be necessary to collect larger volumes
• -observe for shock, pain, nausea, pallor, tachypnea, dyspnea
• -cough is common after lung re-expands
• -usuall no more that 1000 ml removed at one time to prevent re-expansion and pulm edema
• -if bx performed second larger needle w/ cutting edge and collection chamber is used
• -after needle withdrawn, apply pressure and small sterile drsg

• -CXR to r/o pneumothorax and mediastinal shift
• -moitor VS and breath sounds on affected side, compare to unaffected (if sounds diminished worry about pneumothorax)
• -assess for complications such as re-accumulation of fluid, crepitus, infection, and tension pneumothorax (air escaped and pushed lung over, can push on heart and great vessels, we will see hemodynamic changes! assess for tachycardia, watch O2 sat, tracheal deviation...)
• -encourage deep breathing to promote lung re-expansion
• -document pt's tolerance, volume and character of fluid removed and specimens sent to lab, location of puncture site and resp. assessment before, during and after procedure