CHAPTER 27 Results in expiratory airflow limitation

1. Emphysema:
CHRONIC RESPIRATORY - Defined by permanent enlargement
PROBLEMS of air spaces and wall destruction
without fibrosis
Types
Pulmonary Diseases Overview:
1. Centriacinar emphysema: Destruction
• Chronic pulmonary diseases have risen
confined to respiratory bronchioles and
dramatically, expected to increase as the
central acinus
older adult population grows
2. Panacinar emphysema: Whole acinus
• Many respiratory diseases, like asthma
affected; often in AAT-deficient
and COPD, are not reportable, making
individuals
full prevalence estimates challenging
• Chronic pulmonary diseases are a major
Pathogenesis
health issue, contributing to productivity
➢ Protease-antiprotease imbalance
losses and disability payments—
leads to connective tissue destruction in
second only to heart disease
the lung
• COPD is the fourth leading cause of ➢ Cigarette smoke inhibits AAT,
death in the U.S. after heart disease, attracting neutrophils which release
cancer, and stroke elastase, damaging lung elastin
• Symptoms such as cough, breathing
difficulty, sputum production, Clinical Signs
shortness of breath, and irritation in • Increased lung compliance: Loss of
the nose and throat should not be elastic recoil from elastin destruction,
ignored if they persist over two weeks leading to overdistended lungs
• Increased airway resistance: Small
Chronic Obstructive Pulmonary airways collapse during expiration,
Disease (COPD) trapping air and requiring accessory
muscle use
➢ COPD includes chronic bronchitis and
emphysema, leading to airflow
Altered oxygen-CO2 exchange:
limitation
➢ Decreased surface area from alveolar
➢ COPD progresses slowly with stable
destruction impairs gas diffusion
phases and acute exacerbations of
symptoms
Early compensation with increased
➢ Asthma differs due to its unique
respiratory rate; later, respiratory acidosis
inflammation and reversibility
and hypoxemia develop
characteristics

Symptoms include:
Etiology and Epidemiology:
• Insidious onset of dyspnea (initially on
➢ Cigarette smoking is the primary
exertion)
cause, with 90% of COPD patients
• Minimal cough and sputum production.
affected
• Appearance of barrel chest, thin body
➢ Protease-antiprotease imbalances
habitus, pursed-lip breathing, and use
contribute, with alpha-1 antitrypsin
of accessory muscles
(AAT) deficiency leading to
emphysema
Pulmonary function studies
➢ Secondhand smoke, air pollution,
occupational toxins, and infections are • Increased residual volume (RV),
additional risk factors • Functional residual capacity (FRC)
• Total lung capacity (TLC)
Pathophysiology of COPD:
Hallmarks include lung parenchyma Decreased FEV1 and FEV1/VC ratio
destruction (emphysema) and central ✓ Arterial blood gases (ABGs) often near
airway inflammation (chronic bronchitis) normal early; respiratory alkalosis from
hyperventilation
 Chronic Bronchitis Diagnostic and Collaborative Care
Definition: Chronic bronchitis is defined by a Management
chronic productive cough lasting for 3 Underdiagnosis is common (up to 50%
months in each of 2 successive years undiagnosed)
after other causes of chronic cough have
been excluded Pulmonary Function and Spirometry
Tests: Diagnose and monitor progression
Pathologic Changes
➢ Hypertrophy and hyperplasia of 1. Chest X-Ray: Shows flat diaphragm,
mucus-secreting glands increased AP diameter, and
➢ Chronic inflammatory changes in small overdistention of lungs
airways. 2. Arterial Blood Gas (ABG): Early COPD
➢ Excessive mucus production and shows hypoxemia without hypercapnia
impaired ciliary movement increase 3. Sputum Studies: Identify pathogens (S.
susceptibility to infection pneumoniae, H. influenzae).
➢ Bacteria (e.g., Streptococcus 4. Complete Blood Count (CBC): May
pneumoniae, Haemophilus influenzae) show erythrocytosis due to hypoxia
proliferate, causing neutrophilic
chemotaxis and mucopurulent Medications and Treatment
exudate in bronchi. ✓ Bronchoactive Medications: Improve
➢ Granulation tissue and peribronchial airflow and symptoms
fibrosis result in airway obstruction ✓ Anticholinergic Agents: First-line
therapy for bronchodilation (e.g.,
Clinical Manifestations Ipratropium)
➢ Increased airway resistance due to ✓ Beta-Agonists: Second-line therapy
bronchial wall changes, mucosal edema, (e.g., albuterol for short-acting,
and excess mucus salmeterol for long-acting)
➢ Altered oxygen-carbon dioxide exchange ✓ Methylxanthines (e.g., theophylline):
causing V/Q mismatch Enhance respiratory muscle strength but
➢ Obstructed airways may lead to require monitoring
atelectasis (lung collapse) ✓ Combination Therapy: Anticholinergics
➢ Hypercapnia, hypoxemia, and respiratory and beta-agonists
acidosis occur due to altered gas ✓ Corticosteroids: Reduce exacerbations
exchange in moderate-to-severe cases
➢ Cor pulmonale (right ventricular ✓ Mucolytics: Limited evidence for
failure) may develop due to pulmonary effectiveness
hypertension ✓ Antibiotics: For acute exacerbations
with purulent sputum
Early symptom: Productive cough, often ✓ Alpha1-Antitrypsin (AAT)
ignored by smokers as "cigarette cough" Replacement: For patients with AAT
Late-stage symptoms: Constant dyspnea, deficiency
use of accessory muscles, cyanosis due to ✓ Antidepressants and Anxiolytics:
chronic hypoxemia, right-sided heart Treat depression and anxiety in COPD
failure (cor pulmonale), and dusky skin
Smoking Cessation
Disease Progression and Complications • The only intervention proven to slow
✓ Typically progresses over 30 years due lung function decline in COPD
to tobacco smoke exposure • Older adults may respond well to regular,
✓ Major complications: Infection and brief counseling and encouragement
respiratory failure • Nicotine replacement should be carefully
✓ Common in the fifth decade with monitored for overdose signs in older
productive cough or acute chest illness patients
✓ Dyspnea on exertion typically begins in
the sixth or seventh decade
Oxygen Therapy Transtracheal oxygen (TTO) reduces dead
✓ Supplemental oxygen is the only space and oxygen use but requires specific
therapy proven to improve outcomes patient criteria
in advanced COPD
✓ Indications: Patients unable to Aerosol Therapy
maintain PaO₂ > 55 mm Hg or O₂ Delivers bronchoactive medications
saturation > 85% at rest, or unable to effectively with minimal side effects
complete ADLs without shortness of
breath Vaccination
✓ Dosage: Usually 1-2 L/min via nasal Pneumococcal and influenza vaccines
prongs to relieve hypoxemia, reduce are recommended for COPD patients and
pulmonary hypertension, and decrease their close contacts
the right heart load
✓ Goal: Maintain O₂ saturation > 90% Additional Therapy and Rehabilitation
ideally 24 hours per day Encourage mobility: Patients should stay
✓ Activity-related hypoxemia may require active with portable oxygen when needed.
supplemental O₂ during activity or sleep Pulmonary rehabilitation: Enhances
✓ Continuous oxygen therapy is quality of life, reduces hospital stays, and
recommended for patients with cor improves exercise capacity
pulmonale or arrhythmias Sleep and rest: Assess for sleep disorders,
✓ Portable oxygen systems preferred for common in COPD
mobility to improve exercise and cardiac Hospice/Palliative Care: Important as
output. COPD is progressive and ultimately fatal;
focus on comfort and symptom management
Patient Education
Misunderstanding: Patients may think Surgical Management
oxygen should be used only when Lung Transplantation: Considered for
symptomatic to avoid "habituation," which is patients with severe COPD; highest survival
incorrect rate with bilateral transplantation
Lung Volume Reduction Surgery (LVRS):
High-flow oxygen (≥6 L/min or >40% ➢ For patients with severe emphysema
concentration) may risk respiratory failure to ease breathing and improve lung
by reducing the stimulus to breathe in function
patients with chronic CO₂ retention ➢ Criteria: Severe limitation in
pulmonary function, impaired
Oxygen Therapy Assessment & ADLs, non-responsive to medical
Discharge management, and 6-12 weeks of
Before discharge: Check ABG and O₂ rehab completed
saturation at rest, during activity, and sleep
to determine need for home oxygen Health Promotion and Prevention
✓ Education on smoking cessation and
CMS Reimbursement Criteria: respiratory irritants
1. PaO₂ ≤ 55 mm Hg or O₂ saturation ≤ 88% ✓ Screening for AAT deficiency in patients
at rest on room air with family history of emphysema.
2. PaO₂ ≤ 55 mm Hg or O₂ saturation ≤ 88% ✓ Regular influenza and pneumococcal
during exercise vaccines for high-risk individuals.
3. PaO₂ 56-59 mm Hg with heart failure,
pulmonary hypertension, cor
pulmonale, or hematocrit > 56%

Home Oxygen Options

Delivery systems: Liquid oxygen, tank, or
oxygen concentrator
Portable options allow mobility; ambulatory
systems enhance satisfaction and mobility
Oxygen-conserving devices (nasal/pedant
reservoir) save 50% or more oxygen at rest.
 Nursing Diagnosis: Impaired Gas Nursing Diagnosis: Activity Intolerance
Exchange Encourage gradual exercise (e.g., cycling,
• Monitor ABGs for signs of hypoxemia walking)
and hypercapnia ➢ Oxygen during exercise if needed
Symptoms include headache, confusion,
somnolence, asterixis, cardiac dysrhythmias, Support muscle reconditioning:
tachycardia, tachypnea ➢ Start with 10-minute sessions,
➢ Morning headache is often a gradually increasing duration
sign of hypercapnia ➢ Advise patients to balance
• Assess need for supplemental oxygen activities and rest; allow ample time
and patient response for tasks
• Educate on oxygen use: ➢ Assess sleep patterns:
➢ Use at prescribed flow rate; • Nocturnal hypoxemia may
adjust only under guidance worsen symptoms; avoid
➢ Apply water-soluble lubricant benzodiazepines for sleep
(e.g., K-Y Jelly) for dry nasal support.
membranes (avoid petroleum-
based) Nursing Diagnosis: Imbalanced
➢ Check humidifier water levels Nutrition: Less Than Body Requirements
every 6–8 hours • Counsel on a high-protein, high-fat diet
➢ Replace oxygen supply at one- (reduce carbohydrates to avoid elevated
fourth full PaCO₂)
➢ Follow safety precautions: avoid • Recommend frequent small meals
smoking, flammable materials, instead of large meals to conserve
and keep oxygen upright energy
• Suggest easy-to-chew foods to reduce
Nursing Diagnosis: Ineffective Airway effort during eating
Clearance
Encourage effective coughing techniques: Nursing Diagnosis: Risk for Infection
• Huff coughing in an upright Teach infection prevention practices:
position ➢ Proper cleaning and handling of
• Promote fluid intake (3–4 L/day inhalers, nebulizers, and other
unless contraindicated) to thin respiratory devices
secretions • Encourage awareness of respiratory
✓ Water is the preferred symptoms and early intervention for
expectorant infections
• Use chest percussion and postural
drainage for patients with excessive
sputum or lobar atelectasis

Nursing Diagnosis: Ineffective Breathing

Pattern
Teach controlled breathing techniques:
1. Pursed-lip breathing to slow
respiratory rate and reduce air trapping
2. Forward-leaning (tripod) position to
improve exhalation
3. Abdominal breathing for breathing
efficiency
4. Recommend humidified air (30–50%)
and cool air movement (e.g., fan use) for
ease of breathing.
5. Advise on smoking cessation and
avoiding pollutants
 Asthma Collaborative Care Management
Chronic inflammatory disorder of the ✓ Education for a patient-provider
airways partnership
Exaggerated bronchoconstrictor ✓ Self-management to manage symptoms
response (airway narrowing) to stimuli like effectively, maintain quality of life, and
allergens, irritants, cold air, exercise engage in daily activities
Symptoms: Wheezing, dyspnea,
especially at night and early morning Diagnostic Tests
• Peak Expiratory Flow Rate (PEFR):
Etiology & Epidemiology Monitors airflow to assess severity
➢ Results from complex interactions and response to treatment.
among inflammatory cells, mediators,
and airway tissues. Medications
➢ Triggers: Allergen exposure, viral Goals: Promote normal functioning,
infections, exercise, environmental prevent attacks
factors • Common drugs: Beta-agonists,
corticosteroids, anti-inflammatories.
Pathophysiology • Newer approaches: LABAs for
✓ Airflow limitation due to persistent asthma but not as sole
bronchoconstriction, edema, mucus, therapy.
and airway remodeling
✓ Acute bronchoconstriction: Triggered Treatments
by IgE-mediated release of histamine, ✓ Peak flow monitoring: Guides daily
leukotrienes, etc management
✓ Airway edema: Mucosal thickening ✓ Emergent treatment for status
due to increased vascular permeability. asthmaticus: Humidified oxygen,
✓ Chronic mucus plugs: Persistent beta-agonists, corticosteroids, and
airflow limitation in severe asthma NIV preferred over mechanical
✓ Airway remodeling: Irreversible ventilation
structural changes in long-standing
asthma cases Health Promotion & Prevention
✓ Effective patient-provider partnerships
Asthma Classification (NAEPP focusing on lifestyle, support, and trigger
Guidelines) identification
1. Mild intermittent: Symptoms < twice a ✓ Avoidance of triggers to reduce
week. exacerbations
2. Mild persistent: Symptoms > twice a ✓ Healthy People 2010 goals: Aim to
week but not daily. reduce asthma-related issues
3. Moderate persistent: Daily symptoms,
frequent exacerbations.
4. Severe persistent: Continuous
symptoms, frequent exacerbations,
limited activity.

Complications
Status asthmaticus: Uncontrolled severe
attack leading to respiratory failure
Symptoms: Severe distress, cyanosis,
inability to speak.
Requires immediate medical intervention.
Nursing Management of the Patient with Respiratory Failure
Cystic Fibrosis Respiratory failure is the impairment of
the lung's ability to maintain adequate
Nursing Diagnosis: Risk for Infection oxygen and carbon dioxide homeostasis
✓ Maintain environment as pathogen-
free as possible ✓ Diagnosis requires ABGs and pulse
✓ Encourage frequent handwashing for oximetry analysis
the patient, especially after coughing
✓ Provide frequent mouth care, Classified into:
especially after postural drainage. 1. Acute Respiratory Failure (ARF):
✓ Instruct visitors to wash hands before Rapid onset of hypoxemia, hypercarbia,
touching the patient or both, occurring over hours to days
✓ Minimize exposure to people with upper 2. Chronic Respiratory Failure (CRF):
respiratory infections Develops over months to years, with
✓ Monitor temperature regularly, along compensatory mechanisms improving
with sputum color, volume, and oxygen transport and buffering
consistency respiratory acidemia
✓ Collect sputum specimens accurately 3. Acute-on-Chronic Respiratory Failure
for culture and sensitivity (AOCF): ARF superimposed on CRF,
✓ Administer antibiotics on time to maintain e.g., in patients with COPD experiencing
adequate blood levels acute exacerbation

Nursing Diagnosis: Ineffective Airway Respiratory failure can also be classified

Clearance by pathophysiology as:
✓ Assist with coughing, postural 1. Hypoxemic Respiratory Failure: Low
drainage, and percussion every 2 to 4 PaO2 (less than 55 mm Hg), normal or
hours low PaCO2
✓ Utilize FLUTTER valves and Vest 2. Hypoxemic-Hypercapnic Respiratory
System devices to promote Failure: Low PaO2 (less than 55 mm
independence Hg) and high PaCO2 (greater than 50
✓ Auscultate breath sounds before and mm Hg)
after treatments to evaluate effectiveness
✓ Encourage fluid intake of 3 to 4 L/day Pathophysiology
(unless contraindicated). The respiratory system consists of:
✓ Keep the room cool, maintaining ➢ Gas exchange unit (lungs)
temperature below 70°F (21.1°C) ➢ Pump (respiratory muscles and
control mechanisms)
Nursing Diagnosis: Imbalanced
Nutrition: Less Than Body Requirements Any alteration in function of these parts
✓ Perform baseline and periodic nutrition can cause respiratory insufficiency or
assessments failure
✓ Record food history, daily • Inadequate ventilation leads to:
intake/output, and weight ➢ Decreased arterial oxygen,
✓ Monitor blood glucose levels and causing tissue hypoxia
administer insulin as prescribed ➢ Accumulation of carbon
✓ Collaborate with dietitian to provide small, dioxide, resulting in respiratory
frequent, appealing meals acidosis
✓ Administer pancreatic enzymes and
vitamins as ordered Acute Respiratory Failure (ARF) criteria:
✓ PaO2 ≤ 50 mm Hg (on room air)
Nursing Diagnosis: Anticipatory Grieving ✓ PaCO2 ≥ 50 mm Hg
✓ Identify the patient’s stage of grieving ✓ pH ≤ 7.35
✓ Allow time for the patient to express
feelings, hopes, and fears In Chronic Respiratory Failure (CRF), pH
✓ Support expressions of hope while usually stays between 7.35-7.40 due to
avoiding false reassurance compensation
✓ Support the patient and family through
grief and recommend CF support groups.
Acute-on-Chronic Respiratory Failure Treatment for other complications as
(AOCF) results from a secondary insult needed
(e.g., respiratory infection) in CRF patients 1. Mechanical Ventilation
➢ pH drops below 7.35 and • Mechanical ventilation may be
severe hypoxemia occurs necessary when respiratory failure
➢ PaCO2 is less relevant than pH worsens despite medical therapy
and PaO2 Goals of ventilation:
✓ Correct life-threatening blood gas
Blood gas derangements lead to clinical and acid-base abnormalities
signs and symptoms of respiratory failure ✓ Provide support during bronchoactive
pharmacologic therapy
Complications ✓ Rest respiratory muscles to allow
Impaired gas exchange due to: recovery from fatigue
1. Plugged tube, kinked tube, or cuff • Ventilator adjustments are made to
herniation rest respiratory muscles for 48 to 72
2. Fluid volume excess, electrolyte hours
imbalance, stress ulcers, and GI bleeding • Ventilation can be noninvasive (via
3. Infection and increased intracranial face or nasal mask) or invasive (via
pressure due to altered cerebral intubation)
perfusion
4. Tissue hypoxia and cardiopulmonary 2. Noninvasive Mechanical Ventilation
arrest (NIV)
One-year survival rates after respiratory • NIV uses mechanical ventilation
failure: without invasive airway
➢ 28% to 72%
➢ Best prognosis for patients with Criteria for NIV:
kyphoscoliosis or neuromuscular ✓ Moderate to severe shortness of
disease breath
➢ Worst prognosis for patients with ✓ Accessory muscle use
pneumoconiosis and pulmonary ✓ Evidence of respiratory muscle
fibrosis fatigue, acidosis, hypercapnia, or
➢ Men with COPD requiring increased respiratory rate
mechanical ventilation have a 50%
survival rate at 1 year • Improves ABGs, reduces intubation
and mortality rates in COPD with
Diagnostic Tests acute hypercapnic respiratory failure
• ABGs (Arterial Blood Gases) • Methods include negative-pressure
• Chest X-ray studies ventilation and IPPV (Intermittent
• Pulmonary spirometry Positive Pressure Ventilation)
• Sputum for culture and sensitivity • Face or nasal mask with Pressure
Support Ventilation (PSV) or BiPAP
Tests are used to determine disease are common devices
severity and treatment needs
Benefits
Treatments ✓ Relieves symptoms
✓ Therapy is determined by severity of ✓ Improves gas exchange
failure, ventilation needs, and underlying ✓ Reduces hospital stay and
cause mortality
✓ Oxygen therapy and supportive
ventilation are common Complications
• Skin breakdown and aspiration
• Some patients cannot tolerate the
mask

3. Intubation
• Required if NIV is not effective or
patient is not a candidate for NIV
• Intubation is necessary for
mechanical ventilation
4. Ventilator Modes 3. PSV weaning: Gradually reduce
• Common modes include: the preset positive pressure to
1. Assist/Control (A/C): Full ventilatory ease breathing
support, ventilator delivers breath if
patient cannot trigger it 10. Noninvasive Ventilation During
2. Synchronized Intermittent Mandatory Weaning:
Ventilation (SIMV): Patient can take • Use in patients who can breathe
additional breaths over the set rate comfortably post-weaning and
3. CPAP: Set airway pressure throughout have satisfactory ABGs
the respiratory cycle, with the patient
controlling the breaths Failure to Wean
Possible due to:
5. Ventilator Types: ➢ Obstructive lung disease,
➢ Pressure-cycled ventilators: neuromuscular diseases, severe
Deliver positive pressure to reach chest wall deformities
preset pressure, volume varies ➢ Factors like malnutrition,
➢ Volume-cycled ventilators: Deliver electrolyte abnormalities, and
constant volume of air, with recurrent aspiration
pressure adjusted as needed
Nursing diagnoses: Dysfunctional
6. Suctioning the Patient Ventilatory Weaning Response and Impaired
• Use a closed system for suctioning Spontaneous Ventilation
to maintain oxygen supply, stability
of PEEP, and reduce risk of Care for Patients Who Cannot Be Weaned:
ventilator-associated pneumonia ✓ Managed in specialized respiratory units
or long-term care facilities
7. General Care of the Patient on a ✓ Planning for home ventilation requires
Ventilator careful preparation for the equipment and
• Regular assessment of the patient's a responsible caregiver
respiratory status and ventilator
settings Diet
• Alarm troubleshooting: Start with ➢ Diet as tolerated, may be NPO
the patient, then move to the depending on the severity of respiratory
ventilator failure
• Manual ventilation with an Ambu ➢ Proper nutritional support is critical for
bag if needed weaning

8. Tracheostomy Health Promotion and Prevention:

• Considered if ventilation is • Focus on early identification of high-
prolonged beyond 2 weeks for risk patients
comfort, communication, and to avoid Preventive care plan should include:
complications from endotracheal 1. Regular deep breathing and coughing
tubes maneuvers
2. Maintaining optimal activity levels
9. Weaning From the Ventilator: 3. Judicious use of sedatives and
• Goal: To extubate when the patient analgesics
is stable and the precipitating 4. Regular assessment for deterioration in
cause resolves respiratory status
• Preweaning phase: Ensure normal
electrolytes, avoid malnutrition, and
manage caloric intake
Weaning methods
1. T-piece weaning: Disconnect
ventilator, use humidified oxygen,
and observe for respiratory
distress
2. SIMV weaning: Reduce mandatory
breaths and allow more
independent breathing
Nursing Management of the Patient with Nursing Diagnosis: Ineffective Airway
Respiratory Failure Clearance
Nursing Diagnosis: Impaired Gas ✓ Excess mucus is a common cause of
Exchange ARF
✓ Oxygen therapy should be initiated ✓ Positive-pressure ventilation may
rapidly if severe hypoxemia is present. increase mucus production
✓ Effectiveness of oxygen therapy is ✓ Auscultate breath sounds every 1-2
evaluated with ABG measurements and hours during the acute phase
pulse oximetry ✓ Help the patient cough effectively
✓ Provide supplemental oxygen to using the huff technique
maintain a PaO2 of 60 to 90 mm Hg ✓ Change patient position every 2 hours,
✓ High-flow or low-flow oxygen systems elevate the head and chest
can be used for individuals without ✓ Encourage deep breathing exercises
underlying pulmonary disease. or use sigh mechanism on the
✓ Prolonged exposure to high ventilator
concentrations of oxygen can cause ✓ Encourage mobility (out of bed as
oxygen toxicity, resulting in atelectasis tolerated)
and alveolar collapse ✓ Promote adequate fluid intake (3-4 L,
✓ Use the lowest amount of oxygen unless contraindicated) to mobilize
necessary to achieve an acceptable secretions
PaO2 ✓ Use humidification of the airway to
✓ Special precautions for patients with liquefy secretions.
COPD to prevent carbon dioxide ✓ Nasotracheal suctioning if the patient
narcosis cannot cough effectively
✓ Nasal cannula or Venturi mask
preferred for controlled oxygen therapy Nursing Diagnosis: Decreased Cardiac
in COPD patients Output
✓ PaO2 goal: 60 mm Hg (arterial ✓ Decreased cardiac output may be a
saturation ≥ 90%) complication or precipitating factor in
✓ ABG and pulse oximetry should be used ARF
to assess the response to oxygen therapy. ✓ Assess vital signs and hemodynamic
✓ For patients with ARDS, alternative parameters (arterial, central venous,
delivery modes may be required if pulmonary, left atrial pressures) at least
adequate oxygenation cannot be every hour.
achieved without increasing PaCO2. ✓ Monitor for signs of inadequate tissue
✓ Nursing interventions should be firm but perfusion:
empathetic, addressing the patient’s 1. Urinary output <30 ml/hr
agitation or exhaustion from hypoxemia, 2. Cool extremities with
hypercapnia, and increased work of decreased peripheral pulses
breathing. ✓ Watch for cardiac arrhythmias.
✓ Frequent assessment of respiratory
status, vital signs, level of consciousness, Nursing Diagnosis: Imbalanced
ventilator settings, and tolerance of Nutrition: Less Than Body Requirements
ventilatory support. ✓ Nutritional deficits are common due to
✓ Facilitate controlled breathing techniques. increased work of breathing
✓ Review laboratory data, especially ✓ Focus on preventing or correcting
electrolytes and hematocrit. malnutrition
✓ Administer analgesia, especially opiates, ✓ Nutritional intake affects ventilatory drive,
judiciously. respiratory muscle function, and oxygen
consumption
✓ Adequate nutrition is essential for
ventilator weaning
✓ Provide appropriate nutrition to meet the
patient’s specific metabolic needs while
on the ventilator and during weaning.
✓ Enteral supplementation is preferred
when feasible, as it is less risky and more
economical
✓ At least 50% of total calories should Treatment
come from lipids to minimize carbon • Decrease in immunosuppression for
dioxide production early lesions, antivirals (acyclovir,
ganciclovir), chemotherapy for
Lung Transplantation disseminated disease, radiotherapy,
and anti-B-cell monoclonal antibodies
Lung transplantation became a reality in
the 1980s; the first lung transplant in the
Infections: Increased risk post-transplant
U.S. occurred in 1983
• The first heart-lung transplant was
performed in 1981 Obliterative bronchiolitis: Causes severe
• Lung transplants may involve single deterioration of lung function (affects ~50%
lung, double lung, or a lobe of a of recipients after 1 year).
lung. ➢ Irreversible; the only treatment
option is retransplantation
Common conditions requiring lung
transplants include: Symptoms: cough, progressive dyspnea
1. Primary pulmonary Diagnosis: fiberoptic bronchoscopy,
hypertension transbronchial lung biopsy
2. Emphysema
3. Cystic fibrosis (CF) Collaborative Care Management
4. Sarcoidosis • Single lung transplants are performed
5. Pulmonary fibrosis via anterolateral thoracotomy
• Double lung transplants require
➢ Transplantation is a last-resort cardiopulmonary bypass and modified
treatment for severe lung failure bilateral single lung transplant with
➢ Typically performed on patients under 60 individual bronchial anastomoses.
years old, non-smokers, with advanced • For heart-lung transplant:
lung disease ✓ Remove recipient’s heart first,
➢ Single lung transplant: used for then isolate the phrenic nerves
restrictive lung disease ✓ Remove enough left atrium to
➢ Double lung transplant: typically for accommodate the donor’s right
emphysema or CF lung
➢ Lobe transplants: primarily for CF ✓ Tracheal anastomosis
patients completes the process

Complications Immunosuppressive therapy initiated

The survival rate is approximately 80% at 1 immediately, with careful monitoring for
year and 60% at 4 years rejection.
➢ Acute rejection episodes
Major complications: common in the first 6 weeks
✓ Ongoing immunosuppression due to
antirejection drugs Immunosuppressive therapy: drugs like
✓ Lymphoproliferative disorders (PTLD): cyclosporine; corticosteroids avoided in
higher incidence in lung transplant early post-transplant phase to prevent
recipients than other solid organ tracheal/bronchial healing issues
transplants.
Aggressive respiratory care:
Risk factors for PTLD: 1. Frequent position changes, deep
1. Pediatric age, age >55, breathing, postural drainage, and
cytomegalovirus infection, Epstein- coughing
Barr virus, and specific 2. Supplemental oxygen required.
immunosuppressive regimens.
 Cardiovascular monitoring
➢ Risk for complications from hypervolemia,
hypovolemia, myocardial irritability, and
decreased contractility
➢ Hemodynamic status carefully managed
to avoid pulmonary edema and
elevated pulmonary vascular resistance.
• Dysrhythmias common due to
cardiopulmonary bypass
• Coagulation monitoring: careful
management of bleeding risks due to
coagulopathy, anticoagulant use, or
blood product replacement.
➢ Platelet or fresh frozen plasma
may be needed

Preparation for Discharge

✓ Teach the importance of adherence to
the regimen and regular follow-up
monitoring
✓ Exercise: Increased ability for physical
activity but limitations may persist for up
to 2 years