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Nursing Management of Patients with Respiratory Problems

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1. Review of Anatomy and Physiology of the Respiratory System

Structural Organization

• Nose and nasal cavities - filter, warm, and humidify air; lined with ciliated mucosa and goblet cells
• Paranasal sinuses - resonance and mucus secretion
• Pharynx (naso-, oro-, laryngopharynx) - common passage for air and food
• Larynx - houses the vocal cords; contains the epiglottis (prevents aspiration); contains the cough reflex center

• Trachea - 10-12 cm tube reinforced by C-shaped cartilage rings; bifurcates at the carina (T4/T5 level)
• Bronchi - right main bronchus is wider, shorter, more vertical (aspirated objects go here more frequently)
• Bronchioles - no cartilage; contain smooth muscle regulated by the autonomic nervous system
• Alveoli - ~300 million; actual site of gas exchange; lined by type I pneumocytes (gas exchange) and type II pneumocytes (surfactant production)

• Right lung: 3 lobes (upper, middle, lower)
• Left lung: 2 lobes (upper, lower) + lingula
• Covered by visceral pleura; chest wall lined by parietal pleura; potential pleural space between them

Physiology of Breathing

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2. Nursing Assessment

A. History Taking

• Dyspnea - onset (sudden vs. gradual), exertional vs. at rest, orthopnea, paroxysmal nocturnal dyspnea
• Cough - productive vs. dry, duration, character of sputum (color, consistency, amount, odor, blood)
• Hemoptysis - amount, duration, associated symptoms; distinguish from hematemesis
• Chest pain - pleuritic (worse with breathing, sharp) vs. cardiac
• Wheezing / stridor - inspiratory vs. expiratory

• Previous respiratory illness (TB, asthma, recurrent pneumonias)
• Smoking history (pack-years = packs/day × years smoked)
• Occupational and environmental exposures (asbestos, coal, silica, animal dander)
• Allergies, travel history, immunization status (pneumococcal, influenza vaccines)
• Family history (e.g., alpha-1 antitrypsin deficiency, cystic fibrosis)

B. Physical Assessment

• Respiratory rate (normal: 12-20/min), rhythm, depth
• Use of accessory muscles (sternocleidomastoid, scalene, intercostals) = increased work of breathing
• Chest shape: barrel chest (COPD), pectus excavatum/carinatum, kyphoscoliosis
• Cyanosis: peripheral vs. central (examine lips, tongue)
• Clubbing of fingers (chronic hypoxia, bronchiectasis, lung cancer)
• Pursed-lip breathing (COPD adaptation)

• Tracheal position (deviation suggests pneumothorax or tension pneumothorax)
• Chest expansion symmetry
• Tactile fremitus: increased with consolidation, decreased with pleural effusion or pneumothorax
• Crepitus / subcutaneous emphysema

• Normal breath sounds: Vesicular (lung fields), bronchial (over trachea), bronchovesicular (1st-2nd ICS)
• Abnormal (adventitious) sounds:
  • Crackles (rales) - fluid in airways; fine crackles = pneumonia/fibrosis; coarse crackles = secretions
  • Rhonchi - mucus in large airways; clear with coughing
  • Wheeze - high-pitched; narrowed airways (asthma, COPD)
  • Stridor - inspiratory; upper airway obstruction
  • Pleural friction rub - leathery sound; pleuritis

C. Diagnostic Tests

• ABG (Arterial Blood Gas): Gold standard for oxygenation and ventilation status
  • pH, PaO2, PaCO2, HCO3, SaO2; identifies respiratory vs. metabolic acidosis/alkalosis
• CBC: Leukocytosis (infection), polycythemia (chronic hypoxia), eosinophilia (asthma, allergic)
• Sputum culture & sensitivity: Identify causative organism and guide antibiotic therapy
• Blood cultures: Bacteremia/sepsis workup in pneumonia, empyema
• D-dimer: Elevated in PE; high sensitivity, low specificity

• Spirometry: Measures FVC, FEV1, FEV1/FVC ratio - distinguishes obstructive from restrictive
• Peak Flow: Bedside monitoring of airway obstruction severity in asthma

• Chest X-Ray (CXR): First-line; identifies infiltrates (pneumonia), effusions, hyperinflation (COPD), masses
• CT Chest: High-resolution detail; gold standard for PE (CT pulmonary angiography), interstitial disease
• V/Q Scan: Alternative to CT-PA for suspected PE when contrast is contraindicated
• Bronchoscopy: Direct visualization; biopsy, BAL, foreign body retrieval

• Explain procedure and obtain informed consent
• Position properly (ABG - Allen's test first; bronchoscopy - NPO 4-6 hrs prior)
• Monitor post-procedure (post-bronchoscopy: watch for hemorrhage, pneumothorax, laryngospasm)
• Handle specimens correctly (sputum collected morning, first morning specimen before breakfast)

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3. Common Respiratory Problems

A. Upper Respiratory Tract Infections (URTIs)

• Most common respiratory illness
• Causative agents: Rhinovirus (most common), coronavirus, RSV, adenovirus
• Symptoms: Nasal congestion, rhinorrhea, sore throat, low-grade fever, cough - self-limiting (7-10 days)
• Management: Symptomatic - rest, fluids, analgesics/antipyretics, saline nasal rinses
• Nursing: Teach hand hygiene, avoid sharing utensils, droplet precautions

• Acute (<4 weeks), subacute (4-12 weeks), chronic (>12 weeks)
• Viral or bacterial (Streptococcus pneumoniae, Haemophilus influenzae)
• S/S: Facial pain/pressure, purulent nasal discharge, headache, fever, anosmia
• Treatment: Viral - symptomatic; Bacterial - amoxicillin-clavulanate ×10-14 days; nasal corticosteroids
• Nursing: Steam inhalation, saline irrigation (neti pot), elevate head of bed, warm facial compresses

• Most viral; Group A Beta-hemolytic Streptococcus (GABHS) = important bacterial cause
• S/S: Sore throat, odynophagia, fever, tonsillar exudates, lymphadenopathy
• Centor criteria (score 4 = treat empirically): fever, exudate, tender cervical lymph nodes, absence of cough
• Treatment: GABHS - penicillin ×10 days (prevents rheumatic fever); viral = symptomatic
• Nursing: Throat swab before antibiotics, warm saline gargles, soft diet, monitor airway

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B. Chronic Obstructive Pulmonary Disease (COPD)

• Emphysema: Destruction of alveolar walls by proteases (especially neutrophil elastase), loss of elastic recoil, air trapping; "pink puffer" (dyspnea dominant)
  • Centriacinar (centrilobular) - smoking-related, upper lobe predominance
  • Panacinar (panlobular) - alpha-1 antitrypsin deficiency, lower lobe
• Chronic Bronchitis: Persistent productive cough ≥3 months/year for ≥2 consecutive years; mucus gland hyperplasia, goblet cell metaplasia, airway inflammation; "blue bloater" (hypoxia, hypercapnia, edema)

• Progressive dyspnea (initially exertional, then at rest)
• Chronic productive cough
• Barrel chest (increased AP diameter), hyperresonance to percussion
• Decreased breath sounds, prolonged expiration, wheeze
• Pursed-lip breathing (autoPEEP), use of accessory muscles
• Cor pulmonale in advanced disease (peripheral edema, JVD, loud P2)

• Positioning: High Fowler's (60-90°), orthopneic position (over-bed table) to maximize diaphragmatic excursion
• Oxygen Therapy: Controlled low-flow O2 (1-2 L/min via nasal cannula) - maintain SpO2 88-92%; avoid high-flow O2 (may blunt hypoxic drive)
• Pursed-lip breathing: Teach patient - prolongs expiration, prevents airway collapse, reduces air trapping
• Diaphragmatic breathing: Strengthens diaphragm, reduces accessory muscle use
• Pulmonary rehab: Exercise tolerance, pacing activities, energy conservation
• Medications:
  • Short-acting beta-2 agonists (SABA): salbutamol (albuterol) - rescue therapy
  • Long-acting bronchodilators (LABA + LAMA): salmeterol + tiotropium - maintenance
  • Inhaled corticosteroids (ICS): fluticasone - reduce exacerbations (use only in GOLD C/D)
  • Systemic corticosteroids (short course) for acute exacerbations
  • Roflumilast (PDE4 inhibitor): for GOLD C/D with chronic bronchitis
  • Mucolytics: N-acetylcysteine, guaifenesin
• Airway Clearance: Chest physiotherapy, postural drainage, flutter valve, incentive spirometry
• Exacerbation Management (AECOPD):
  • Increase bronchodilators, systemic steroids 5 days (prednisolone 40 mg), antibiotics if purulent sputum (amoxicillin-clavulanate, azithromycin), NIV (BiPAP) if respiratory failure
• Patient Education: Smoking cessation (#1 priority), vaccines (influenza annually, pneumococcal), energy conservation, inhaler technique

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C. Asthma

• Atopic asthma (extrinsic): Th2-mediated, IgE-dependent; allergen exposure → mast cell degranulation (early phase: bronchospasm, mucus) → inflammatory cell influx (late phase: eosinophils, cytokines IL-4, IL-5, IL-13)
• Non-atopic asthma (intrinsic): Triggered by viral infections, cold air, exercise, pollutants, aspirin
• Airway remodeling: Subbasement membrane thickening, smooth muscle hypertrophy - may add irreversible component
• Eosinophils are key inflammatory cells; eosinophil major basic protein damages airway epithelium

• Episodic wheeze, cough (especially nocturnal), chest tightness, dyspnea
• Reversibility (spontaneously or with bronchodilators) distinguishes from COPD
• Prolonged expiration, hyperresonance, decreased breath sounds during attack

• Acute Attack (status asthmaticus emergency):
  • Position: Sit upright, orthopneic position
  • O2 to maintain SpO2 ≥95%
  • Nebulized SABA (salbutamol) every 20 min × 3 doses
  • Ipratropium bromide (anticholinergic) added for severe attacks
  • Systemic corticosteroids (IV methylprednisolone or oral prednisolone)
  • IV Magnesium sulfate for severe/life-threatening attacks
  • Monitor: Peak flow, SpO2, respiratory rate, accessory muscle use
  • Prepare for intubation/mechanical ventilation if deteriorating
• Long-term Control (step-up therapy):
  • Step 1 (intermittent): SABA PRN only
  • Step 2: Low-dose ICS (first-line controller)
  • Step 3: Low-dose ICS + LABA
  • Step 4: Medium-dose ICS + LABA
  • Step 5: Biologics (omalizumab anti-IgE; mepolizumab anti-IL-5 for eosinophilic asthma)
• Inhaler Technique: Shake, exhale, seal lips, activate + slow deep breath, hold 10 sec; spacer recommended for MDI
• Peak Flow Monitoring: Green (>80%), Yellow (50-80% - caution), Red (<50% - emergency)
• Asthma Action Plan: Written personalized plan with trigger avoidance, medication escalation, when to seek emergency care

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D. Pleural Effusion and Empyema

• Transudative: Low protein; due to increased hydrostatic or decreased oncotic pressure
  • Causes: Heart failure (#1), cirrhosis, nephrotic syndrome
• Exudative: High protein, high LDH; due to increased capillary permeability or impaired lymphatic drainage
  • Causes: Pneumonia, malignancy, TB, PE, autoimmune diseases
  • Light's criteria: Exudate if pleural protein/serum protein >0.5 OR pleural LDH/serum LDH >0.6 OR pleural LDH >2/3 upper limit of normal

• Dyspnea, dull or pleuritic chest pain
• Decreased/absent breath sounds over effusion
• Dullness to percussion, decreased tactile fremitus
• CXR: Blunting of costophrenic angle (>200 mL needed), meniscus sign; massive = mediastinal shift

• Pus in the pleural space; complication of pneumonia, thoracic surgery, trauma
• Stages: Exudative → Fibrinopurulent → Organizing (pleural peel)
• Causative organisms: Streptococcus pneumoniae, Staphylococcus aureus, anaerobes
• S/S: Fever, pleuritic chest pain, dyspnea, malaise; pleural fluid pH <7.2, glucose <60 mg/dL, LDH >1000

• Thoracentesis nursing care:
  • Position: Sitting upright leaning forward over bedside table (or lateral decubitus for ultrasound-guided)
  • Mark site (usually posterior, above rib to avoid neurovascular bundle)
  • Monitor: Vital signs, SpO2 before, during, and after procedure
  • Post-procedure CXR to check for pneumothorax
  • Limit fluid drainage to 1000-1500 mL at a time to prevent re-expansion pulmonary edema
• Chest Tube (Tube Thoracostomy) Care for Empyema:
  • Ensure water-seal chamber has water to correct level; look for tidaling (rises with inspiration, falls with expiration = good)
  • Bubbling in suction chamber = suction working; unexpected bubbling in water-seal = air leak
  • Keep drainage bottles below chest level
  • Milking/stripping only if ordered (controversial); clamp only when ordered
  • Monitor: Drainage amount, color, consistency; suture line and dressing
  • Document drainage every shift
• Antibiotics: IV broad-spectrum; fibrinolytics (streptokinase, alteplase) instilled via chest tube for loculated empyema; surgical decortication for organized empyema
• Semi-Fowler's to Fowler's position; encourage deep breathing; incentive spirometry

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E. Bronchiectasis

• Post-infectious (TB, whooping cough, measles - most common in developing countries)
• Cystic fibrosis (#1 cause in developed countries)
• Immunodeficiency syndromes
• Obstruction (foreign body, tumor)
• Kartagener's syndrome (primary ciliary dyskinesia)
• Allergic bronchopulmonary aspergillosis (ABPA)

• Classic triad: Chronic productive cough, copious purulent sputum (three-layer appearance on standing: frothy top, mucous middle, purulent sediment), recurrent pulmonary infections
• Hemoptysis (can be massive - from erosion of bronchial artery)
• Dyspnea, wheeze, crackles (wet, coarse)
• Clubbing of fingers in chronic cases
• HRCT chest: Signet ring sign (dilated bronchus with adjacent pulmonary artery), tram-track sign (thickened bronchial walls)

• Airway Clearance (Priority #1):
  • Postural drainage: 2-4 times daily, 15-30 minutes per position; on empty stomach; use gravity to drain specific segments
  • Chest percussion/vibration: Apply over draped chest wall during exhalation
  • Active Cycle of Breathing Techniques (ACBT)
  • Flutter valve / Oscillating PEP devices
  • Nebulized hypertonic saline (3-7%) to loosen secretions
  • Adequate hydration (2-3 L/day if no contraindication)
• Medications:
  • Antibiotics: Based on sputum culture; Pseudomonas aeruginosa common - requires anti-pseudomonal antibiotics (ciprofloxacin, tobramycin)
  • Bronchodilators: For bronchospasm
  • Mucolytics: DNase (dornase alfa) in cystic fibrosis
• Hemoptysis management: Position with affected side down (to protect uninvolved lung), maintain airway, IV access, blood type and crossmatch, notify physician
• Patient education: Daily airway clearance routine, signs of exacerbation, smoking cessation, vaccinations
• Surgical option: Lobectomy for localized disease with failure of medical therapy

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F. Pneumonia

• Lobar: Entire lobe consolidated; classic S. pneumoniae; 4 stages (congestion, red hepatization, grey hepatization, resolution)
• Bronchopneumonia: Patchy, multifocal; affects bronchi + adjacent alveoli
• Interstitial: Atypical pathogens; diffuse, bilateral

• Fever, chills, productive cough (rust-colored sputum = S. pneumoniae; pink frothy = Klebsiella "currant jelly")
• Pleuritic chest pain, dyspnea
• Consolidation signs: Increased fremitus, dull percussion, bronchial breath sounds, egophony ("E to A" changes), whispered pectoriloquy
• CXR: Lobar or patchy infiltrates

• Airway and Breathing:
  • Semi-Fowler's to High Fowler's position
  • O2 therapy to maintain SpO2 >94%
  • Encourage deep breathing and coughing; incentive spirometry
  • Chest physiotherapy; postural drainage if secretions heavy
• Infection Control:
  • Droplet precautions (standard for most pneumonias)
  • Airborne precautions for TB, varicella, measles
  • Hand hygiene; oral care every 2-4 hrs (reduces VAP)
• Medications:
  • CAP (outpatient): Amoxicillin ± macrolide or doxycycline
  • CAP (inpatient): Beta-lactam + macrolide or respiratory fluoroquinolone
  • HAP/VAP: Anti-pseudomonal beta-lactam + aminoglycoside or fluoroquinolone ± MRSA coverage (vancomycin/linezolid)
  • Antipyretics, analgesics for pleuritic pain
• Fluid and Nutritional Support: IV fluids for dehydration; monitor I&O; NG/oral feeds based on swallow assessment
• Monitoring: Vital signs, SpO2, RR, mental status (confusion = deterioration); ABG for respiratory failure
• Complications to Watch: Sepsis, respiratory failure, pleural effusion/empyema, bacteremia, lung abscess
• Prevention: Pneumococcal vaccine (PPSV23, PCV15/20), influenza vaccine annually, early ambulation, aspiration precautions, VAP bundle (HOB 30-45°, oral chlorhexidine, sedation holidays)

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G. Lung Abscess

• Aspiration (#1 cause) - impaired consciousness (alcohol, seizure, anesthesia), dysphagia, poor dentition
• Pneumonia complication (Staphylococcus, Klebsiella)
• Septic emboli (right-sided endocarditis, IV drug use)
• Obstructing tumor

• Indolent onset: weeks of malaise, anorexia, weight loss, night sweats
• Productive cough with copious foul-smelling sputum (sudden large volume = abscess ruptures into bronchus)
• Fever, pleuritic chest pain
• CXR/CT: Cavity with air-fluid level; usually right lower or middle lobe (aspiration position)

• Position: Affected side down initially then postural drainage; semi-Fowler's to high Fowler's
• Airway Clearance: Postural drainage 2-4×/day; percussion; encourage coughing; adequate hydration
• Medications:
  • Prolonged antibiotics (4-8 weeks): IV penicillin + metronidazole OR amoxicillin-clavulanate → oral step-down
  • Clindamycin (excellent anaerobic coverage; current preferred agent)
• Monitoring: Temperature trends (fever resolution takes 2-3 weeks), sputum character and quantity, CXR response, nutritional status
• Surgical Intervention: Percutaneous drainage or surgical resection if:
  • No response after 6 weeks of antibiotics
  • Abscess >6 cm
  • Ruptured into pleura causing empyema
• Nutrition: High protein, high calorie diet; oral care before/after meals; NG feeds if needed
• Oral hygiene: Critical - poor dentition is major predisposing factor; dental hygiene education

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H. Cysts and Tumors of the Lung

• Hydatid cyst (Echinococcus granulosus): Endemic in sheep-rearing areas; CXR shows "water lily sign" if ruptured; surgical excision (PAIR procedure)
• Pulmonary sequestration: Non-functioning lung tissue with anomalous arterial supply; surgical resection

• New or changing cough, hemoptysis, unexplained weight loss, persistent hoarseness (recurrent laryngeal nerve), dysphagia (esophageal compression), facial/arm swelling (SVC syndrome - SCLC)
• Pancoast tumor: Apical tumor → Horner's syndrome (ptosis, miosis, anhidrosis), brachial plexopathy, shoulder pain

• Preoperative (for lobectomy/pneumonectomy):
  • Thorough chest physiotherapy to optimize lung function
  • Smoking cessation at least 8 weeks preoperatively
  • Incentive spirometry teaching
  • Deep breathing, coughing exercises
• Postoperative care:
  • Monitor chest tube drainage (post-lobectomy: drainage should resolve; post-pneumonectomy: NO chest tube on negative suction - only water seal)
  • Position: Operative side down (post-pneumonectomy) to allow remaining lung to expand fully
  • Aggressive pain management (epidural, intercostal nerve block) to enable deep breathing
  • Early ambulation
• Chemotherapy/Radiation nursing:
  • Manage side effects: Nausea, mucositis, fatigue, myelosuppression, radiation pneumonitis
  • Nutritional support
  • Psychological support; palliative care discussions
• Palliative Care: Dyspnea management (opioids reduce air hunger), pain control, psychosocial and spiritual support, advance directive discussions

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I. Chest Injuries

• Most common chest injury; pain causes splinting → inadequate ventilation → atelectasis, pneumonia
• Nursing: Adequate analgesia (epidural ideal), incentive spirometry, deep breathing; avoid chest binders
• Flail chest: ≥3 consecutive ribs fractured in ≥2 places → paradoxical movement (segment moves in with inspiration, out with expiration)
  • Emergency: Positive pressure ventilation, aggressive analgesia, surgical fixation for severe cases

• Simple (Spontaneous): Air in pleural space without external injury; primary (tall thin young males, subpleural bleb rupture) or secondary (complication of COPD, asthma)
• Traumatic: Blunt or penetrating chest trauma
• Tension pneumothorax: EMERGENCY - one-way valve; air accumulates → contralateral mediastinal shift → cardiovascular collapse
  • Signs: Absent breath sounds (affected side), tracheal deviation AWAY from lesion, hypotension, JVD, respiratory distress, hypoxia
  • Treatment: Immediate needle decompression (2nd ICS, MCL) → chest tube
• Open pneumothorax ("sucking chest wound"): Cover with 3-sided occlusive dressing (prevents tension)

• Blood in pleural space; usually from intercostal or internal mammary artery injury
• Massive hemothorax: >1500 mL blood; treat with large-bore chest tube (28-32 Fr)
• Nursing: IV access × 2, fluid resuscitation, blood type and crossmatch, chest tube care, prepare for thoracotomy if needed

• Beck's triad: Hypotension, muffled heart sounds, JVD
• Emergency pericardiocentesis; pericardial window if recurrent

• Airway: Establish patent airway; suction, intubate if needed
• Breathing: O2 high flow; assess breath sounds every hour; chest tube management
• Circulation: Two large-bore IVs; fluid resuscitation; blood products; cardiac monitoring
• Disability/Neuro: GCS; cervical spine protection in trauma
• Pain management: Critical - inadequate pain relief → splinting → complications
• Documentation: Mechanism of injury, vital signs trends, drainage amounts
• Wound care: Chest tube site care; sterile technique; occlusive dressings for open wounds

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J. Acute Respiratory Distress Syndrome (ARDS)

1. Acute onset within 1 week of a known insult or new/worsening respiratory symptoms
2. Bilateral opacities on CXR/CT not fully explained by effusions, collapse, or nodules
3. Respiratory failure not fully explained by cardiac failure (echo to exclude cardiogenic pulmonary edema if no clear risk factor)
4. PaO2/FiO2 ratio (P:F ratio):
   • Mild: 200-300 (with PEEP ≥5 cmH2O)
   • Moderate: 100-200 (with PEEP ≥5 cmH2O)
   • Severe: <100 (with PEEP ≥5 cmH2O)

• Mechanical Ventilation - Lung Protective Strategy (ARDSNET Protocol):
  • Low tidal volume: 6 mL/kg of ideal body weight (not actual)
  • Plateau pressure ≤30 cmH2O
  • PEEP: Titrated to FiO2 using PEEP-FiO2 tables; high PEEP for moderate-severe ARDS
  • Goal: SpO2 88-95% or PaO2 55-80 mmHg; permissive hypercapnia acceptable
• Prone Positioning: 12-16 hours/day for severe ARDS (P:F <150); improves V/Q matching; requires specialized team; eye and skin protection
• Conservative Fluid Strategy: Neutral to negative fluid balance once hemodynamically stable; reduces pulmonary edema
• Neuromuscular blockade: Cisatracurium infusion for 48 hours in moderate-severe ARDS (may reduce inflammatory injury)
• Sedation/Analgesia: Pain-sedation-delirium bundle; daily sedation awakening trials; Richmond Agitation Sedation Scale (RASS)
• Prevention of Complications:
  • VAP bundle: HOB 30-45°, oral chlorhexidine, sedation vacations, subglottic suctioning
  • DVT prophylaxis (LMWH)
  • Stress ulcer prophylaxis (PPI)
  • Pressure injury prevention (turns every 2 hrs, specialty mattress)
  • Nutritional support: Enteral nutrition within 24-48 hrs; avoid overfeeding

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K. Pulmonary Embolism (PE)

1. Stasis: Immobility, long-haul travel, heart failure, obesity
2. Hypercoagulability: Malignancy, thrombophilia (factor V Leiden), oral contraceptives, pregnancy
3. Endothelial injury: Surgery, trauma, central venous catheters

• Classic triad (uncommon): Dyspnea + pleuritic chest pain + hemoptysis
• More commonly: Unexplained tachycardia + dyspnea
• Massive PE: Hemodynamic instability (SBP <90), syncope, right heart failure
• Low-grade fever, pleural friction rub, S1Q3T3 on ECG (right heart strain)
• D-dimer elevated (high sensitivity, low specificity); troponin/BNP elevated in massive PE (RV strain)

• Wells Criteria: Clinical scoring (score ≤4 = PE unlikely; >4 = PE likely)
• CT Pulmonary Angiography (CTPA): Gold standard
• V/Q scan: Alternative when CT contraindicated (pregnancy, renal failure, contrast allergy)

• Acute Phase:
  • O2 therapy - high flow, target SpO2 ≥95%
  • Two large-bore IV lines
  • Continuous cardiac monitoring (watch for right heart strain, arrhythmias)
  • Bed rest with HOB elevated; minimize exertion
  • IV fluids cautiously (RV already strained)
• Anticoagulation:
  • Unfractionated heparin (UFH): IV infusion in massive/submassive PE; weight-based dosing; monitor aPTT 1.5-2.5× control; HIT risk
  • LMWH (enoxaparin): SC; preferred in stable PE and cancer-associated PE
  • Direct oral anticoagulants (DOACs): Rivaroxaban, apixaban - now preferred for most stable PE (EINSTEIN, AMPLIFY trials)
  • Duration: Provoked PE (3-6 months); unprovoked or recurring (6-12 months+)
• Thrombolysis (tPA): Reserved for massive PE with hemodynamic instability; monitor for major bleeding
• Surgical embolectomy / Catheter-directed thrombolysis: For massive PE with failed thrombolysis or contraindication
• IVC filter: For recurrent PE despite anticoagulation or when anticoagulation contraindicated
• Monitoring: Vital signs, cardiac rhythm, urine output, signs of re-embolization, bleeding (anticoagulation)
• DVT prevention (primary prevention of PE): Early ambulation postoperatively, sequential compression devices (SCDs), LMWH prophylaxis, adequate hydration, compression stockings
• Patient Education: Anticoagulation adherence, bleeding precautions, avoid prolonged immobility, compression stockings during travel

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4. Health Behaviors to Prevent Respiratory Illness

Primary Prevention

• Single most important preventable cause of respiratory disease
• Resources: Nicotine replacement therapy (patch, gum, lozenge, inhaler), varenicline (Chantix), bupropion
• "5 A's" approach: Ask, Advise, Assess, Assist, Arrange follow-up
• Benefits begin within 20 minutes; cough improves at 1-9 months; FEV1 decline slows

• Influenza vaccine: Annual; all persons ≥6 months; reduces influenza, pneumonia complications
• Pneumococcal vaccines: PCV15 or PCV20 (adults ≥65, immunocompromised, chronic lung disease)
• COVID-19: Primary series + boosters per current schedule
• Pertussis (Tdap): Adults/adolescents; prevent whooping cough
• Measles/MMR: Prevent measles pneumonia

• Avoid or reduce exposure to secondhand smoke, air pollutants, dust, mold
• Workplace engineering controls (masks, ventilation) for occupational exposures
• Indoor air quality: Air purifiers, avoid biomass cooking fuels
• Radon testing in homes (second leading cause of lung cancer)

• Hand hygiene: The most effective measure against respiratory infections
• Respiratory etiquette: Cough/sneeze into elbow; tissue disposal
• Avoid touching eyes, nose, mouth; avoid close contact with sick individuals
• Face masks in crowded spaces during outbreaks

• Regular moderate exercise improves lung function and immune response
• Balanced diet rich in antioxidants (vitamins C, E, beta-carotene) supports airway defense
• Maintain healthy body weight (obesity impairs diaphragmatic excursion)
• Adequate hydration maintains mucociliary clearance

• Pre-employment respiratory assessment for high-risk jobs
• Regular spirometry surveillance for workers exposed to silica, asbestos, coal dust
• Proper use of PPE (N95 respirators, powered air-purifying respirators)

Secondary Prevention (Early Detection)

• Annual low-dose CT (LDCT) chest screening: Recommended for high-risk individuals (age 50-80, ≥20 pack-year history, current smoker or quit <15 years) per USPSTF guidelines
• TB screening (TST/IGRA) for high-risk groups (immigrants, healthcare workers, HIV+)
• Pulmonary rehabilitation: For established chronic disease to prevent complications and hospitalizations

Tertiary Prevention (Prevent Complications)

• Medication adherence (inhaler technique, COPD/asthma maintenance therapy)
• Self-monitoring tools (peak flow meters for asthma, pulse oximeters)
• Flu and pneumonia vaccines in COPD/asthma patients (prevent exacerbations)
• Early recognition of exacerbation signs and prompt medical care

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Summary Table: Key Nursing Priorities by Condition

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1. Anatomy & Physiology - URT/LRT structure, lung volumes, V/Q matching, control of breathing, normal values table
2. Nursing Assessment - Full history taking framework (PQRST, smoking history, occupational exposure), physical exam (inspection, palpation, percussion, auscultation with abnormal breath sounds), and all diagnostic tests with nursing responsibilities
3. Upper RTIs - Common cold, sinusitis, pharyngitis with Centor criteria, croup, epiglottitis
4. COPD - Emphysema vs. chronic bronchitis pathophysiology, GOLD staging, full nursing management including oxygen safety, pursed-lip breathing, medications, exacerbation management
5. Asthma - Th2/IgE pathophysiology, trigger types, severity classification, acute attack management (SABA/ipratropium/steroids/MgSO4), step-up therapy, inhaler technique, peak flow zones
6. Pleural Effusion/Empyema - Light's criteria, chest tube care with water-seal monitoring, thoracentesis nursing care
7. Bronchiectasis - Postural drainage technique, flutter valve, airway clearance priority, signet ring/tram-track HRCT signs
8. Pneumonia - CAP/HAP/VAP classification, CURB-65 scoring, VAP bundle, antibiotic guidance
9. Lung Abscess - Anaerobic microbiology, postural drainage, clindamycin therapy, indications for surgery
10. Cysts and Tumors - Lung cancer types (adenocarcinoma, SCC, SCLC, large cell), paraneoplastic syndromes, Pancoast/Horner's, perioperative and palliative nursing
11. Chest Injuries - Rib fractures, flail chest, tension pneumothorax (needle decompression), hemothorax, cardiac tamponade
12. ARDS - Berlin criteria, ARDSNET lung-protective ventilation (6 mL/kg, plateau ≤30), prone positioning, conservative fluids
13. Pulmonary Embolism - Virchow's triad, Wells criteria, anticoagulation types, thrombolysis indications, DVT prevention
14. Health Behaviors - Smoking cessation 5 A's, vaccines, hand hygiene, LDCT screening criteria, occupational health