UNIT 4 Nursing Management of patients with respiratory problems
๐ซ ANATOMY AND PHYSIOLOGY OF THE RESPIRATORY SYSTEM
๐ฌ๏ธ INTRODUCTION
The respiratory system is responsible for the exchange of gases (oxygen and carbon dioxide) between the body and the environment. It works closely with the circulatory system to supply oxygen to tissues and remove carbon dioxide from the body.
๐ง DIVISIONS OF RESPIRATORY SYSTEM
It is divided into:
1. Upper Respiratory Tract
Nose and Nasal Cavity
Pharynx (Throat)
Larynx (Voice box)
2. Lower Respiratory Tract
Trachea
Bronchi and Bronchioles
Lungs
Alveoli
๐ DETAILED ANATOMY
1. Nose and Nasal Cavity
External nose has nostrils (nares).
Internal nasal cavity is lined with mucosa and has turbinates (conchae) to warm, filter, and humidify air.
Contains olfactory receptors for smell.
2. Pharynx
A muscular tube divided into three parts:
Nasopharynx (behind the nose)
Oropharynx (behind the mouth)
Laryngopharynx (connects to larynx and esophagus)
Passageway for both food and air.
3. Larynx
Also called the voice box.
Contains vocal cords.
Made of cartilages (e.g., thyroid cartilage โ Adamโs apple, cricoid, epiglottis).
Epiglottis prevents food from entering the airway.
4. Trachea
Also known as the windpipe.
10โ12 cm long tube with C-shaped cartilaginous rings.
Lined with ciliated epithelium that moves mucus upward.
5. Bronchi and Bronchioles
Trachea divides into right and left primary bronchi.
Bronchi subdivide into secondary and tertiary bronchi, and then into bronchioles.
End in terminal bronchioles and then respiratory bronchioles.
6. Lungs
Located in thoracic cavity, separated by mediastinum.
Right lung has 3 lobes; left lung has 2 lobes (space for heart).
Covered by pleura (double-layered membrane):
Visceral pleura (covers lung surface)
Parietal pleura (lines chest wall)
Pleural cavity contains lubricating fluid.
7. Alveoli
Tiny air sacs for gas exchange.
Surrounded by capillaries.
Walls are made of Type I pneumocytes (for gas exchange) and Type II pneumocytes (secrete surfactant).
Surfactant reduces surface tension and prevents alveolar collapse.
๐ซ PHYSIOLOGY OF RESPIRATION
Respiration involves four main processes:
1. Pulmonary Ventilation (Breathing)
Movement of air in and out of lungs.
Includes:
Inhalation (Inspiration): Active process, diaphragm and intercostal muscles contract.
(Objective Nursing Assessment for Respiratory Disorders)
๐น Purpose
To identify and evaluate signs of respiratory distress, altered lung function, or pathology such as pneumonia, asthma, COPD, TB, pleural effusion, pneumothorax, etc.
๐ง COMPONENTS OF RESPIRATORY PHYSICAL ASSESSMENT
Physical assessment includes Inspection, Palpation, Percussion, and Auscultation โ also known as IPPA method.
โ 1. PREPARATION OF PATIENT & ENVIRONMENT
Ensure privacy, adequate lighting, and ventilation.
Provide comfortable positioning: sitting upright or semi-Fowlerโs.
Risk for fluid volume deficit r/t fever and decreased intake
Interventions:
Encourage warm fluids, rest
Administer medications as prescribed (antipyretics, antibiotics)
Provide steam inhalation/gargles
Monitor temperature, SpOโ, respiratory rate
Educate patient on hand hygiene and cough etiquette
Evaluation:
Relief from congestion, pain, and fever
Normal temperature and respiratory function
No signs of complications
๐น PREVENTION OF URTIs
Regular handwashing
Mask wearing in crowded places (especially during flu/COVID season)
Avoid sharing utensils, towels
Stay home during illness to prevent spread
Vaccination:
Influenza vaccine (yearly)
COVID-19 vaccination
Pneumococcal vaccine (if high-risk)
Avoid smoking/passive smoke
Good nutrition and hydration to boost immunity
๐คง COMMON COLD (Acute Viral Rhinitis)
๐น DEFINITION
The common cold, also known as acute viral rhinitis, is a mild, self-limiting upper respiratory tract infection caused by a virus. It primarily affects the nose, nasal passages, throat (pharynx), sinuses, and sometimes the larynx, leading to symptoms like sneezing, nasal congestion, sore throat, and cough.
It is the most frequent infectious illness in all age groups.
Usually viral in origin, it resolves within 7โ10 days without specific treatment.
๐น CAUSES
๐ฆ Etiological Agents (Viruses)
Virus
Approximate % of cases
Rhinoviruses
30โ50% (most common)
Coronaviruses
10โ15%
Adenoviruses
5โ10%
Respiratory Syncytial Virus (RSV)
Common in children
Parainfluenza virus
May cause cold + croup
Enteroviruses
Less common
Influenza virus
Cold-like symptoms possible
๐ Predisposing Factors
Cold weather (winter months)
Children under 6 years of age
Exposure to infected individuals
Poor hygiene
Immunocompromised state
Smoking or secondhand smoke
Stress and fatigue
๐น PATHOPHYSIOLOGY OF COMMON COLD (RHINITIS)
1. Viral Entry:
Virus enters through the nose, eyes, or mouth, usually by inhalation of droplets or direct contact with contaminated surfaces.
2. Attachment to Nasal Epithelium:
Viruses (especially rhinoviruses) attach to receptors on nasal epithelial cells (e.g., ICAM-1 for rhinovirus).
They enter the cells and begin replicating.
3. Local Inflammatory Response:
Infected cells release cytokines and inflammatory mediators (histamine, prostaglandins, bradykinin).
This causes:
Vasodilation โ nasal congestion
Increased vascular permeability โ runny nose (rhinorrhea)
Nerve stimulation โ sneezing, irritation
Increased mucus production โ congestion and cough
4. Immune Response Activation:
Neutrophils and lymphocytes are recruited to the site.
Secretory IgA and interferons play a role in controlling viral replication.
5. Systemic Effects:
Mild fever, fatigue, and malaise may occur due to cytokine effects.
Secondary bacterial infection is rare but can occur (sinusitis, otitis media).
6. Resolution:
Symptoms peak in 2โ3 days, then gradually improve.
Epithelial regeneration occurs within a week.
Immunity is short-lived and specific to the virus subtype; reinfection with other strains is common.
๐น SIGNS AND SYMPTOMS
The onset is usually gradual, and symptoms typically appear 1โ3 days after exposure to the virus. Most cases resolve within 7โ10 days, though a mild cough may linger for 1โ2 weeks.
Symptom
Description
Nasal congestion
Swelling of nasal passages due to inflammation
Runny nose (Rhinorrhea)
Clear, watery nasal discharge; may turn yellow or green as infection progresses
Sneezing
Frequent, reflex action due to irritation of nasal mucosa
Sore throat
Mild to moderate pain, scratchiness, often the first symptom
Cough
Usually dry at first, may become productive later
Mild fever
Usually low-grade (<101ยฐF or 38.5ยฐC), more common in children
Headache
Dull, frontal headache due to sinus congestion
Fatigue or malaise
Feeling of general tiredness and body ache
Watery eyes
Due to nasolacrimal duct inflammation
Postnasal drip
Mucus trickling down the throat, can cause irritation and coughing
Hoarseness
Occasional, if larynx is involved (mild laryngitis)
Loss of smell/taste
Temporary due to nasal blockage
๐ข Note: Symptoms like high fever (>101ยฐF), facial pain, ear pain, or thick discolored mucus may indicate bacterial superinfection (sinusitis, otitis media) rather than simple viral rhinitis.
๐น DIAGNOSIS
The diagnosis of the common cold is clinical, meaning it is based on the history and physical examination. Laboratory tests are usually not required unless complications or alternative diagnoses are suspected.
โ Clinical Diagnosis โ Key Components:
History Taking
Gradual onset
Exposure to infected individuals
No history of allergies or bacterial illness
Physical Examination
Red, swollen nasal mucosa
Watery or mucopurulent nasal discharge
Mild pharyngeal erythema (red throat)
No exudates or lymphadenopathy (helps differentiate from bacterial pharyngitis)
Normal or slightly elevated temperature
Clear chest on auscultation (no lung involvement)
๐ฌ Investigations (Only If Needed)
Test
When Used
Purpose
Throat swab (Rapid Strep Test or culture)
If severe sore throat, fever, or exudates
Rule out streptococcal pharyngitis
COVID-19 / Influenza PCR test
If suspected based on history
Rule out viral infections with similar symptoms
CBC (Complete Blood Count)
If symptoms persist >10 days or fever is high
Differentiate between viral and bacterial infection
Chest X-ray
Not routine
Only if signs of pneumonia or lower respiratory tract infection appear
Allergy testing
If recurrent episodes
Rule out allergic rhinitis
๐น A. MEDICAL MANAGEMENT
Since the common cold is usually viral, the treatment is mainly symptomatic and supportive. Antibiotics are NOT indicated unless there is a secondary bacterial infection.
โ 1. General Supportive Measures
Rest: To promote healing and reduce fatigue.
Hydration: Increase fluid intake to thin secretions and prevent dehydration.
Nutrition: Light, nutritious, and warm meals to boost immunity.
โ 2. Symptomatic Drug Therapy
Medication Type
Examples
Purpose
Antipyretics & Analgesics
Paracetamol, Ibuprofen
Reduce fever, headache, body ache
Decongestants (Oral/Nasal)
Pseudoephedrine, Xylometazoline (nasal spray)
Relieve nasal congestion by shrinking swollen mucosa
Antihistamines
Cetirizine, Chlorpheniramine
Reduce sneezing, runny nose, watery eyes
Cough suppressants
Dextromethorphan
Used if dry, irritating cough is present
Expectorants
Guaifenesin
Loosen and thin mucus for productive cough
Saline nasal drops/spray
Normal saline
Moisturizes and clears nasal passages
Throat lozenges or warm saline gargles
โ
Soothe sore throat and reduce irritation
๐ข Note: Nasal decongestant sprays should not be used for more than 3โ5 days, as they can cause rebound congestion (rhinitis medicamentosa).
โ 3. Antiviral Medications
Generally not required for routine common cold.
Antivirals (like oseltamivir) may be considered only in specific cases of confirmed influenza in high-risk patients.
โ 4. Antibiotics
Not used routinely in viral rhinitis.
Prescribed only if:
Bacterial sinusitis or otitis media develops
Purulent nasal discharge lasts >10 days
High-grade fever persists
Common antibiotics: Amoxicillin-clavulanic acid, Azithromycin
๐ด Avoid:
Overuse of nasal decongestants
Self-medication with antibiotics
Smoking, alcohol, or cold exposure during illness
๐น B. SURGICAL MANAGEMENT
โก๏ธ Surgery is NOT required for simple common cold. However, recurrent or chronic rhinitis, or complications like sinusitis or nasal obstruction, may need surgical intervention.
Deviated nasal septum contributing to recurrent infections
Chronic or recurrent sinusitis not responding to medical treatment
โ Surgical Procedures May Include:
Surgery
Purpose
Septoplasty
Correction of a deviated nasal septum
Turbinate reduction
To reduce the size of swollen turbinates
Polypectomy
Removal of nasal polyps
Functional Endoscopic Sinus Surgery (FESS)
To clear chronic sinus infection and improve sinus drainage
Adenoidectomy (in children)
If enlarged adenoids cause recurrent colds or ear infections
๐ฉโโ๏ธ NURSING MANAGEMENT OF COMMON COLD (ACUTE VIRAL RHINITIS)
๐น A. ASSESSMENT
The first step in nursing care is to collect relevant subjective and objective data.
โ Subjective Data:
Complaint of sore throat, nasal congestion, or runny nose
Fatigue or headache
Reports of sneezing or cough
History of exposure to someone with a cold
โ Objective Data:
Nasal discharge (watery or mucoid)
Mild fever (low-grade)
Redness or swelling in nasal mucosa or throat
Vital signs: slightly elevated temperature, normal respiratory rate
No lung abnormality on auscultation
๐น B. COMMON NURSING DIAGNOSES
Nursing Diagnosis
Related To
Evidenced By
Ineffective airway clearance
Nasal congestion and mucus
Difficulty breathing, blocked nose
Acute pain
Inflammation of throat/sinuses
Patient reports sore throat or headache
Hyperthermia
Viral infection
Fever, warm skin
Disturbed sleep pattern
Nocturnal cough, congestion
Complains of poor sleep
Deficient knowledge
Lack of awareness
Questions about medications, transmission
๐น C. NURSING INTERVENTIONS AND RATIONALES
Nursing Intervention
Rationale
Encourage rest and limit strenuous activity
Promotes healing and conserves energy
Encourage oral fluids (2โ3 liters/day)
Keeps mucosa hydrated and helps thin secretions
Administer antipyretics (e.g., paracetamol) as prescribed
Helps reduce fever and discomfort
Provide saline nasal drops or steam inhalation
Relieves nasal congestion and promotes easier breathing
Offer warm saline gargles
Soothes sore throat and reduces inflammation
Maintain proper room ventilation
Ensures clean air and reduces viral load
Monitor vital signs, especially temperature and respiratory rate
Helps detect complications like sinusitis or lower respiratory tract infection
Educate patient about hand hygiene and cough etiquette
Prevents spread to others
Instruct not to use over-the-counter nasal sprays for >3โ5 days
Prevents rebound nasal congestion
Teach when to seek medical help (e.g., high fever, ear pain, prolonged symptoms)
Early detection of complications
๐น D. EVALUATION
The nursing care is considered effective if:
Patient reports reduced nasal congestion and pain
Fever subsides
Sleep and appetite improve
Patient demonstrates correct hygiene practices
No signs of complications are observed
๐น E. PATIENT & FAMILY EDUCATION
Disease nature: It is viral and self-limiting.
Transmission: Spread via droplets and contact.
Prevention: Handwashing, using tissues/masks, avoiding close contact.
Medication use: Proper use of decongestants, pain relievers.
When to return: If fever >3 days, severe ear or sinus pain, or breathing difficulty develops.
โ ๏ธ COMPLICATIONS OF COMMON COLD (ACUTE VIRAL RHINITIS)
Although the common cold is usually mild and self-limiting, complications can occur, especially in vulnerable groups (children, elderly, immunocompromised).
๐น 1. Secondary Bacterial Infections
Sinusitis: Inflammation of paranasal sinuses causing facial pain, pressure, and purulent nasal discharge.
Otitis media: Middle ear infection, especially in children; causes earache and fever.
Bronchitis: Infection spreads to the lower airway, leading to productive cough.
Pneumonia: Serious lung infection if the virus descends into the lungs or bacteria superimpose.
๐น 2. Exacerbation of Preexisting Conditions
Asthma: Viral rhinitis can trigger an asthma attack.
Chronic Obstructive Pulmonary Disease (COPD): Increased risk of acute exacerbation.
๐น 3. Rhinitis Medicamentosa
Rebound nasal congestion due to overuse of topical nasal decongestant sprays.
๐น 4. Laryngitis
Inflammation of the larynx leading to hoarseness or loss of voice.
๐น 5. Conjunctivitis
Eye redness and irritation may occur if virus spreads to conjunctiva.
๐ KEY POINTS ON COMMON COLD (RHINITIS)
โ๏ธ Definition: A viral infection of the upper respiratory tract, especially the nose and throat.
โ๏ธ Causative Agents: Mainly rhinoviruses, followed by coronaviruses, RSV, adenoviruses, etc.
โ๏ธ Transmission: Airborne droplets and direct contact (very contagious).
โ๏ธ Symptoms:
Sneezing, runny nose, nasal congestion
Sore throat, mild fever
Cough, fatigue, headache
โ๏ธ Diagnosis: Clinical; based on history and physical exam. Lab tests not usually needed.
โ๏ธ Management:
Symptomatic treatment only
No antibiotics unless secondary bacterial infection is suspected
Pharyngitis is the inflammation of the pharynx (the back of the throat), typically causing sore throat, discomfort during swallowing, and sometimes fever. It can be acute or chronic, and is commonly caused by viral or bacterial infections.
In acute pharyngitis, symptoms appear suddenly and resolve within a week.
In chronic pharyngitis, symptoms are persistent or recurring, often due to irritants or allergies.
Viruses or bacteria enter through inhalation of droplets, or via direct contact with contaminated surfaces.
Common portal of entry: mouth and nose
๐ 2. Invasion of Pharyngeal Mucosa
Pathogens attach to epithelial cells of the pharynx.
They begin to multiply and trigger local tissue damage.
๐ 3. Inflammatory Response
Infected cells release cytokines and inflammatory mediators (e.g., histamine, prostaglandins).
Leads to:
Vasodilation and capillary leakage โ redness and swelling
Sensitization of nerve endings โ sore throat, pain during swallowing
Increased mucus production โ throat irritation, cough
๐ 4. Immune Reaction
Activation of immune cells (neutrophils, lymphocytes).
In bacterial pharyngitis (especially streptococcal), tonsillar exudate, fever, and lymphadenopathy are more pronounced.
๐ 5. Resolution or Progression
Viral pharyngitis is usually self-limiting and resolves in 3โ5 days.
Bacterial pharyngitis, if untreated, may cause complications such as rheumatic fever or glomerulonephritis.
๐น SIGNS AND SYMPTOMS
Symptoms may vary depending on whether the cause is viral, bacterial, or non-infectious.
โ Common Symptoms (All Types)
Symptom
Description
Sore throat
Most common symptom; pain or irritation in the throat
Pain during swallowing (Odynophagia)
Especially when eating or drinking
Dry or scratchy throat
Due to inflammation of mucosa
Redness of the throat (pharyngeal erythema)
Seen on inspection
Swollen tonsils
With or without pus
Hoarseness or muffled voice
If larynx is involved
Fever
Low in viral; high in bacterial
Swollen, tender lymph nodes
Particularly in the neck (cervical lymphadenopathy)
Headache and malaise
Especially in systemic viral infections
Cough and nasal symptoms
Usually seen in viral pharyngitis
White or yellow exudates on tonsils
More common in streptococcal infection
Bad breath (halitosis)
Especially in bacterial infections
Body aches and fatigue
In viral causes like influenza or EBV
โ ๏ธ Distinctive Features Based on Cause
Feature
Viral Pharyngitis
Bacterial (Strep) Pharyngitis
Onset
Gradual
Sudden
Fever
Mild/absent
High (>101ยฐF or 38.5ยฐC)
Cough
Common
Usually absent
Nasal congestion
Present
Absent
Tonsillar exudates
Rare
Common
Cervical lymphadenopathy
Mild
Tender and enlarged
Rash (scarlet fever)
Rare
Possible
Duration
3โ5 days
5โ10 days without treatment
๐น DIAGNOSIS OF PHARYNGITIS
Diagnosis is based on:
Clinical examination
Throat inspection
History of symptoms
Laboratory tests (if bacterial cause suspected)
โ Clinical Examination
Inspect throat using a penlight: Look for redness, tonsil swelling, exudates, uvula position, and posterior pharynx.
Check for fever, enlarged cervical lymph nodes, and other systemic signs.
Use Centor Criteria to help decide if streptococcal testing is needed.
๐ข Centor Criteria (Modified)
(Add 1 point for each of the following):
Criteria
Point
Fever >38ยฐC
+1
Tonsillar exudate
+1
Tender anterior cervical lymph nodes
+1
No cough
+1
Age 3โ14
+1
Age >45
โ1
Score 2โ3: Consider testing. Score โฅ4: Treat empirically or confirm with test.
โ Laboratory Tests (If Needed)
Test
Purpose
Rapid Antigen Detection Test (RADT)
Quick test for Group A Streptococcus (results in minutes)
Throat swab culture
Gold standard for strep; takes 24โ48 hrs
Complete Blood Count (CBC)
โ WBC count may indicate bacterial infection
Monospot test
Detects Epstein-Barr Virus (if infectious mononucleosis is suspected)
COVID-19 or Influenza test
If associated symptoms or outbreak present
๐น A. MEDICAL MANAGEMENT
The primary goal is to relieve symptoms, eliminate infection (if bacterial), and prevent complications like rheumatic fever or abscess formation.
โ 1. Supportive/Symptomatic Treatment
(Mainly for Viral Pharyngitis)
Treatment
Examples
Purpose
Rest
–
Allows immune system recovery
Hydration
Warm fluids, soups
Keeps mucosa moist, reduces dryness
Saltwater gargles
1 tsp salt in warm water
Reduces throat inflammation
Analgesics & Antipyretics
Paracetamol, Ibuprofen
Reduces fever, sore throat, headache
Throat lozenges or sprays
Benzocaine, lidocaine
Provides local pain relief
Steam inhalation
–
Relieves nasal and throat congestion
Soft, bland diet
Warm, non-irritating foods
Minimizes throat irritation
โ 2. Antibiotic Therapy
(Only for confirmed or highly suspected bacterial pharyngitis, especially Group A Streptococcus)
Antibiotic
Dose & Duration
Notes
Penicillin V (oral)
500 mg 2โ3 times/day for 10 days
Drug of choice
Amoxicillin
500 mg 2โ3 times/day
Often used in children
Azithromycin
500 mg on Day 1, then 250 mg for 4 days
Used if penicillin allergy
Cephalosporins
Cephalexin, etc.
Alternative in mild penicillin allergy
โ ๏ธ Note: Antibiotics prevent complications like rheumatic fever and post-streptococcal glomerulonephritis, especially if started within the first 9 days.
โ 3. Antivirals
Not usually required for pharyngitis.
May be used if caused by Herpes simplex or Influenza virus.
โ 4. Corticosteroids
Short course may be prescribed for severe inflammation or swelling causing pain or difficulty swallowing.
Prednisolone is commonly used under supervision.
๐น B. SURGICAL MANAGEMENT
Surgical treatment is not routine for simple pharyngitis. However, in recurrent, chronic, or complicated cases, surgery may be indicated.
โ Indications for Surgery
Recurrent bacterial pharyngitis (especially with tonsillitis) โฅ5 episodes/year
Chronic hypertrophic tonsils/pharynx
Peritonsillar abscess (quinsy)
Airway obstruction due to enlarged tonsils or adenoids
Suspected malignancy in chronic ulcerated pharynx (rare)
โ Surgical Procedures
Surgery
Description
Purpose
Tonsillectomy
Surgical removal of tonsils
Done in chronic tonsillitis or recurrent strep pharyngitis
Adenoidectomy
Removal of adenoid tissue (esp. in children)
Improves breathing, reduces recurrent URTIs
Incision and drainage
Of peritonsillar abscess
Emergency relief of pus collection
Biopsy of pharyngeal tissue
If ulcer or tumor suspected
Rule out cancer or TB
โ ๏ธ Post-Surgical Nursing Care
Monitor for bleeding
Provide cold fluids to reduce swelling
Pain management
Observe for airway obstruction
Educate on signs of infection or bleeding at home
๐ฉโโ๏ธ NURSING MANAGEMENT OF PHARYNGITIS
(Acute or Chronic Inflammation of the Pharynx)
๐น A. NURSING ASSESSMENT
โ Subjective Data:
Reports of sore throat or pain during swallowing
Sensation of dryness or scratchiness in the throat
Fatigue, headache, and hoarseness
โ Objective Data:
Red and inflamed pharyngeal mucosa
Enlarged or exudative tonsils
Fever (low- to high-grade)
Swollen cervical lymph nodes
White patches (bacterial infection)
Nasal congestion or cough (in viral causes)
๐น B. COMMON NURSING DIAGNOSES
Nursing Diagnosis
Related To
Evidenced By
Acute Pain
Inflammation of the pharyngeal mucosa
Reports of sore throat, difficulty swallowing
Ineffective airway clearance
Swelling, mucus accumulation
Noisy breathing, congestion
Hyperthermia
Infection
Elevated body temperature
Risk for fluid volume deficit
Reduced intake due to pain
Dry mucous membranes, concentrated urine
Impaired verbal communication
Pain, inflammation, hoarseness
Weak, hoarse, or absent voice
Knowledge deficit
Lack of awareness about disease and prevention
Questions about treatment, home care
๐น C. NURSING INTERVENTIONS AND RATIONALES
Nursing Interventions
Rationale
Assess and document throat appearance and pain level
Helps monitor severity and progression
Encourage rest and limit talking
Conserves energy and reduces strain on inflamed tissues
Administer prescribed analgesics/antipyretics (e.g., paracetamol, ibuprofen)
Relieves pain and fever
Provide warm saline gargles several times daily
Soothes throat, reduces inflammation and bacteria
Offer cool fluids, soft diet (soups, porridge)
Easier to swallow and prevents dehydration
Maintain hydration โ encourage 2โ3 L fluids/day
Keeps mucosa moist and helps eliminate toxins
Monitor temperature, respiratory status, and intake-output
Detects fever trends and signs of systemic involvement
Apply warm compress to neck (if lymph nodes are tender)
Provides comfort and reduces swelling
Instruct patient to avoid irritants (smoke, alcohol, spicy foods)
Prevents further irritation of throat
Educate on proper antibiotic use (if prescribed)
Prevents complications and antibiotic resistance
Promote hand hygiene and respiratory etiquette
Prevents spread of infection to others
Monitor for complications (ear pain, rash, breathing difficulty)
Early detection of serious conditions like abscess or rheumatic fever
๐น D. PATIENT AND FAMILY EDUCATION
Importance of completing full course of antibiotics
Use masks if in shared spaces during contagious period
When to seek help:
High fever lasting >3 days
Difficulty breathing or swallowing
Pus in throat, ear pain, rash, or stiff neck
๐น E. EVALUATION CRITERIA
The nursing goals are met if:
The patient reports relief from throat pain
Fever subsides
Hydration and oral intake are adequate
Patient is free from complications
Patient demonstrates understanding of infection prevention
โ ๏ธ COMPLICATIONS OF PHARYNGITIS
Complications can arise if pharyngitis is left untreated, especially in bacterial cases (like Group A Streptococcal infection).
๐ด 1. Peritonsillar Abscess (Quinsy)
Collection of pus beside the tonsil
Causes severe throat pain, drooling, trismus (jaw stiffness), and difficulty swallowing
May require surgical drainage
๐ด 2. Acute Rheumatic Fever
Autoimmune complication following untreated streptococcal pharyngitis
Affects heart (rheumatic heart disease), joints, brain, and skin
Prevented by timely antibiotic treatment
๐ด 3. Post-Streptococcal Glomerulonephritis
Inflammatory kidney condition after strep throat
Presents with hematuria, edema, and hypertension
๐ด 4. Otitis Media
Infection of the middle ear, especially in children
Ear pain, hearing loss, and fever
๐ด 5. Sinusitis
Inflammation of sinuses due to ascending infection
Causes headache, facial pain, nasal congestion
๐ด 6. Airway Obstruction
From massive tonsillar swelling or abscess formation
Can be life-threatening, especially in children
๐ด 7. Chronic Pharyngitis
Recurrent untreated episodes may lead to persistent inflammation
Symptoms include sore throat, dryness, cough, and throat clearing
โ KEY POINTS ON PHARYNGITIS
โ๏ธ Definition: Inflammation of the pharynx, commonly causing sore throat.
โ๏ธ Causes:
Viral (most common): rhinovirus, adenovirus, EBV
Bacterial: Group A Streptococcus (GAS)
Non-infectious: allergies, smoking, dry air
โ๏ธ Symptoms:
Sore throat, pain on swallowing
Redness, fever, swollen lymph nodes
Tonsillar exudate (bacterial)
Cough, hoarseness (viral)
โ๏ธ Diagnosis:
Clinical exam
Throat swab (culture or rapid strep test)
Centor criteria to predict streptococcal infection
โ๏ธ Treatment:
Viral: supportive (gargles, analgesics, fluids)
Bacterial: antibiotics (penicillin, amoxicillin)
Symptom relief with antipyretics and throat lozenges
โ๏ธ Surgery (when indicated):
Tonsillectomy for recurrent or obstructive cases
Drainage for peritonsillar abscess
โ๏ธ Prevention:
Early treatment of sore throat
Hand hygiene, cough etiquette
Avoid irritants like smoke or pollutants
โ๏ธ Nursing Role:
Pain and fever management
Monitoring for complications
Patient education on medication adherence and hygiene
๐ TONSILLITIS
๐น DEFINITION
Tonsillitis is the inflammation of the tonsils, particularly the palatine tonsils, usually due to infection (viral or bacterial). It is a common condition in children, but can occur at any age.
Tonsillitis may be:
Acute (sudden onset, short duration)
Chronic (recurrent or persistent symptoms)
Recurrent (multiple episodes per year)
๐น CAUSES
โ 1. Infectious Causes
A. Viral (most common, ~70%)
Adenovirus
Rhinovirus
Influenza and Parainfluenza viruses
Epstein-Barr virus (EBV) โ may cause infectious mononucleosis
Coronavirus
B. Bacterial (more severe, ~30%)
Group A Streptococcus (Streptococcus pyogenes) โ most common bacterial cause
Staphylococcus aureus
Haemophilus influenzae
Mycoplasma pneumoniae
โ 2. Predisposing Factors
Poor oral hygiene
Close contact with infected individuals
Immunosuppression
Exposure to smoke or allergens
History of frequent upper respiratory infections
๐น PATHOPHYSIOLOGY
Infection enters through oral or nasal route
Organism reaches tonsillar crypts โ initiates local invasion
Tonsillar tissue becomes swollen, red, and may develop exudates (pus)
Lymph nodes may enlarge due to immune response
In severe cases, infection may extend to surrounding tissues โ abscess formation
๐น SIGNS AND SYMPTOMS
Symptom
Description
Sore throat
Main complaint, often severe
Pain on swallowing (odynophagia)
Especially with solid foods
Fever
Mild to high-grade
Headache and body ache
Due to systemic infection
Red and swollen tonsils
Often with white or yellow patches (exudate)
Enlarged cervical lymph nodes
Tender nodes under the jaw or neck
Halitosis (bad breath)
Common in bacterial tonsillitis
Muffled voice (โhot potatoโ voice)
Due to swollen tonsils
Ear pain
Referred pain from throat
Loss of appetite and fatigue
Especially in children
๐น DIAGNOSIS
โ Clinical Examination
Visual inspection of oropharynx: swollen tonsils with/without pus
Palpation of cervical lymph nodes
Fever, halitosis, and red pharynx
โ Lab Tests
Test
Purpose
Throat swab culture
Confirms bacterial cause (esp. Group A Strep)
Rapid Antigen Detection Test (RADT)
Fast detection of strep throat
Complete Blood Count (CBC)
โ WBCs in bacterial infection
Monospot test
If EBV (infectious mononucleosis) suspected
๐น MEDICAL MANAGEMENT
Treatment
Purpose
Analgesics/Antipyretics (Paracetamol, Ibuprofen)
Reduce pain and fever
Antibiotics (if bacterial)
Penicillin V, Amoxicillin for 10 days; Azithromycin for penicillin allergy
Throat lozenges
Soothe irritation
Warm saline gargles
Reduce local inflammation and discomfort
Hydration and soft diet
Prevent dehydration and ease swallowing
Antihistamines/decongestants
If nasal symptoms are present
Steroids (short course)
For severe swelling or tonsillar hypertrophy (as prescribed)
๐ก Note: Complete full antibiotic course to prevent rheumatic fever and post-streptococcal complications
๐น SURGICAL MANAGEMENT
โ Indications for Tonsillectomy:
Recurrent tonsillitis (โฅ5โ7 episodes/year)
Chronic tonsillitis with bad breath or tonsillar stones
Peritonsillar abscess not responding to treatment
Obstructive sleep apnea due to enlarged tonsils
Suspicion of malignancy (rare)
โ Procedure:
Tonsillectomy: Surgical removal of palatine tonsils under general anesthesia
May be combined with Adenoidectomy if enlarged adenoids are also present
โ Post-op Nursing Care:
Monitor for bleeding (especially within 24 hours and again at 7โ10 days)
Encourage cold fluids and soft food
Monitor for airway obstruction
Administer pain relief
Educate on signs of complications (bleeding, infection)
๐น NURSING MANAGEMENT
โ Nursing Assessment:
Throat pain, difficulty swallowing
Vital signs, fever monitoring
Observe tonsillar size, exudate, and lymph node enlargement
โ Nursing Diagnoses:
Acute pain r/t inflammation of tonsils
Risk for deficient fluid volume r/t reduced intake
Hyperthermia r/t infection
Imbalanced nutrition: less than body requirement
Knowledge deficit r/t disease and prevention
โ Nursing Interventions:
Intervention
Rationale
Encourage warm saline gargles
Soothes throat, reduces inflammation
Administer medications as prescribed
Relieve pain, reduce infection
Encourage fluids and soft foods
Prevent dehydration and irritation
Monitor temperature and throat status
Detect worsening or complications
Educate on hygiene and antibiotic adherence
Prevent spread and recurrence
Monitor for airway obstruction or abscess
Especially in severe or recurrent cases
โ Patient Education:
Complete full antibiotic course
Avoid sharing utensils
Maintain good oral hygiene
Follow up if symptoms worsen or recur
๐น COMPLICATIONS
Complication
Description
Peritonsillar abscess
Pus collection near tonsil causing severe pain, trismus
Otitis media
Middle ear infection via Eustachian tube
Rheumatic fever
Autoimmune reaction after untreated strep infection
Post-streptococcal glomerulonephritis
Kidney inflammation
Obstructive sleep apnea
Due to chronic tonsillar enlargement
Sepsis
Rare but serious in severe bacterial infections
๐น KEY POINTS
โ๏ธ Tonsillitis = inflammation of tonsils, often viral or bacterial โ๏ธ Group A Strep is the most common bacterial cause โ๏ธ Symptoms: sore throat, fever, swollen tonsils with/without pus โ๏ธ Diagnosis: clinical + throat swab or rapid strep test โ๏ธ Treatment: supportive for viral, antibiotics for bacterial โ๏ธ Tonsillectomy indicated for chronic/recurrent or obstructive cases โ๏ธ Nursing care: pain management, hydration, monitoring for complications โ๏ธ Complications include abscess, rheumatic fever, and kidney issues
๐ต LARYNGITIS
๐น DEFINITION
Laryngitis is the inflammation of the larynx (voice box), particularly affecting the vocal cords. It leads to hoarseness, loss of voice, and throat discomfort. It can be:
Acute (short-term, <3 weeks)
Chronic (lasting more than 3 weeks)
๐น CAUSES
โ 1. Infectious Causes
A. Viral (Most Common)
Rhinovirus
Influenza virus
Parainfluenza
Adenovirus
Respiratory Syncytial Virus (RSV)
COVID-19 (SARS-CoV-2)
Herpes Simplex Virus (rare)
B. Bacterial
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis (less common)
C. Fungal
Candida albicans (seen in immunocompromised or steroid inhaler users)
This impairs voice production and causes hoarseness, weak voice, or whispering
๐ 4. Recovery or Chronic Progression
In acute laryngitis, inflammation resolves within a few days with rest and treatment
In chronic laryngitis, repeated or continuous irritation causes thickening, polyp formation, or permanent vocal cord damage
๐น SIGN AND SYMPTOMS
The symptoms of laryngitis depend on the severity, cause, and whether the condition is acute or chronic.
โ COMMON SYMPTOMS (Both Acute & Chronic)
Symptom
Description
Hoarseness
Most common symptom; voice may sound raspy, breathy, or strained
Loss of voice (Aphonia)
Partial or complete inability to speak
Sore throat or raw sensation
Especially during speaking or swallowing
Dry or scratchy throat
Often associated with frequent throat clearing
Dry cough
Persistent, irritating, non-productive
Tickling or lump sensation in the throat
May cause urge to clear throat
Mild fever
More common in viral laryngitis
Fatigue or malaise
If associated with a viral infection
Difficulty swallowing (dysphagia)
Mild to moderate, especially with throat pain
Swollen lymph nodes
In bacterial or viral causes
Breathing difficulty (rare)
In children (may indicate croup or epiglottitis)
๐ก Chronic Laryngitis May Also Present With:
Persistent hoarseness (>3 weeks)
Frequent need to clear throat
Throat discomfort without obvious infection
Reduced vocal range (especially in singers or speakers)
๐น DIAGNOSIS OF LARYNGITIS
Diagnosis is based on clinical evaluation, but may involve further tests if symptoms persist or are severe.
โ 1. Clinical History and Physical Examination
Ask about:
Recent upper respiratory infections
Voice usage (e.g., public speaking, singing)
Exposure to irritants (smoke, allergens)
GERD symptoms
Observe for:
Hoarseness, aphonia
Throat redness
Associated nasal or chest symptoms
โ 2. Laryngoscopy(Key Diagnostic Tool)
Flexible or rigid fiberoptic laryngoscope used to directly visualize:
Swollen, red vocal cords
Presence of nodules, polyps, or ulcers
Vocal cord movement
Useful in chronic laryngitis or when malignancy is suspected
โ 3. Throat Swab / Culture
If bacterial or fungal infection suspected (e.g., white patches, persistent pain)
Helps identify Streptococcus, Candida, etc.
โ 4. Voice Assessment
In chronic or occupational cases
May involve evaluation by a speech-language pathologist
โ 5. Additional Investigations (If Needed)
Test
Purpose
CBC (Complete Blood Count)
Identify infection or inflammation
Monospot test
If Epstein-Barr Virus is suspected
Chest X-ray or CT scan
Rule out underlying lung or mediastinal pathology
Gastroesophageal pH monitoring
In chronic laryngitis suspected from GERD
Biopsy
If a mass or non-healing lesion is seen (to rule out cancer)
โ Important: If hoarseness lasts >3 weeks without obvious cause, it must be investigated further to rule out laryngeal cancer or chronic irritant exposure.
๐น A. MEDICAL MANAGEMENT
Medical treatment for laryngitis depends on the cause โ whether viral, bacterial, fungal, allergic, or non-infectious (e.g., voice overuse or GERD).
โ 1. General Supportive Measures (All Cases)
Measure
Purpose
Voice rest
Minimizes strain on vocal cords and promotes healing
Hydration
Keeps mucosa moist and thins mucus
Warm fluids and humidified air
Soothes throat and relieves dryness
Steam inhalation
Reduces inflammation and congestion
Avoid irritants
No smoking, alcohol, or dusty environments
Whispering discouraged
Also strains vocal cords โ silence is better
โ 2. Drug Therapy Based on Cause
Medication
Indication
Examples
Analgesics / Antipyretics
For pain and fever
Paracetamol, Ibuprofen
Antibiotics
If bacterial infection suspected
Amoxicillin, Azithromycin
Antifungals
For fungal laryngitis (e.g., candida)
Nystatin, Fluconazole
Antihistamines
If allergic laryngitis
Cetirizine, Loratadine
Proton Pump Inhibitors (PPIs)
If GERD-induced
Omeprazole, Pantoprazole
Corticosteroids (short course)
For severe inflammation or edema of vocal cords
Prednisolone (oral) or Dexamethasone (IV/IM in emergencies)
โ ๏ธ Steroids are used cautiously and only under physician supervision โ especially when airway obstruction is suspected.
โ 3. Speech Therapy (For Chronic or Occupational Laryngitis)
Provided by a speech-language pathologist
Focuses on voice training, breathing techniques, and vocal hygiene
๐น B. SURGICAL MANAGEMENT
Surgery is rarely required in laryngitis but may be necessary in chronic, recurrent, or complicated cases.
โ Indications for Surgical Intervention
Vocal cord polyps, nodules, or cysts due to chronic voice misuse
Laryngeal papillomas (benign tumors)
Suspicion of laryngeal cancer
Persistent airway obstruction
Vocal cord paralysis or scarring
โ Common Surgical Procedures
Surgery
Purpose
Microlaryngoscopy
Visualize and treat vocal cord lesions
Microlaryngeal surgery (MLS)
Removal of nodules, polyps, or cysts using micro-instruments or laser
Laryngeal biopsy
If mass is present and malignancy suspected
Tracheostomy
Emergency airway access if severe swelling obstructs breathing (rare)
Injection laryngoplasty
For vocal cord paralysis โ bulks up paralyzed cord for better voice
โ Post-Surgical Care
Voice rest for 1โ2 weeks
Soft diet and hydration
Pain management
Monitor airway for swelling or obstruction
Speech therapy if needed post-op
๐ฉโโ๏ธ NURSING MANAGEMENT OF LARYNGITIS
๐น A. NURSING ASSESSMENT
โ Subjective Data:
Hoarseness or loss of voice
Sore or scratchy throat
Dry cough
History of voice overuse, recent viral infection, GERD, or smoking
Rule out serious causes if symptoms persist >3 weeks
โ๏ธ Medical Management:
Voice rest, hydration, humidified air
Analgesics, antibiotics (if bacterial), antifungals or PPIs (if indicated)
Steroids in severe inflammation
โ๏ธ Surgical Management:
For nodules, polyps, or airway obstruction
Tracheostomy in rare emergencies
โ๏ธ Nursing Care:
Promote voice rest and hydration
Educate about vocal hygiene
Monitor for airway obstruction or chronic changes
โ๏ธ Complications:
Vocal cord damage, nodules
Airway blockage
Misdiagnosis of serious laryngeal disease
๐ก SINUSITIS
(Also called rhinosinusitis)
๐น DEFINITION
Sinusitis is the inflammation or infection of the paranasal sinuses, which are air-filled cavities in the skull. It is usually associated with blockage of sinus drainage, leading to accumulation of mucus, bacterial overgrowth, and pressure.
Can be acute, subacute, chronic, or recurrent.
Often occurs after an upper respiratory tract infection or allergy.
Aspergillus (mainly in immunocompromised or diabetics)
โ 2. Non-Infectious / Predisposing Factors
Cause
How it Contributes
Nasal polyps
Obstruct sinus drainage
Deviated nasal septum
Affects airflow and drainage
Allergic rhinitis
Swelling leads to obstruction
Upper respiratory infections
Inflammation spreads to sinuses
Smoking
Irritates mucosa and impairs ciliary function
Air pollution / dust exposure
Increases risk of mucosal irritation
Dental infections
Can spread to maxillary sinuses
Swimming/diving
Force water into sinuses causing irritation
Barotrauma (air travel)
Pressure changes block drainage
๐น PATHOPHYSIOLOGY OF SINUSITIS
๐ 1. Mucosal Swelling and Obstruction
Triggered by infection, allergy, or irritants.
Swelling blocks sinus ostia (openings).
Air is trapped, and mucus cannot drain.
๐ 2. Accumulation of Secretions
Mucus builds up inside sinuses.
Oxygen is absorbed, creating a negative pressure โ draws in bacteria or viruses.
๐ 3. Inflammatory Response
Local immune response causes:
Vasodilation
Increased mucus production
Neutrophil infiltration
Pressure builds up โ facial pain and headache.
๐ 4. Infection and Complications
Bacterial overgrowth may occur.
Chronic inflammation can lead to:
Mucosal thickening
Polyp formation
Bone erosion (rare)
๐น SIGN AND SYMPTOMS
Symptoms vary depending on whether the sinusitis is acute, chronic, or due to allergy/infection. They typically occur after or along with a cold, allergy, or nasal congestion.
โ Common Signs and Symptoms of Acute Sinusitis:
Symptom
Description
Facial pain or pressure
Localized over the affected sinus (e.g., forehead for frontal sinus, cheeks for maxillary sinus)
Nasal congestion/blockage
Feeling of stuffy or blocked nose
Purulent nasal discharge
Thick yellow or green mucus from the nose
Postnasal drip
Mucus draining into the throat, often causing irritation or cough
Headache
Often frontal or around the eyes, worsens with bending forward
Tooth pain
Especially in upper jaw (maxillary sinusitis)
Fever
May be present in bacterial infections
Fatigue
Generalized tiredness due to infection and poor sleep
Loss of smell (anosmia)
Common in both acute and chronic cases
Halitosis (bad breath)
Due to accumulated infected secretions
Ear pressure or fullness
Due to eustachian tube involvement
๐ก Symptoms Specific to Chronic Sinusitis (>12 weeks):
Nasal obstruction and congestion
Persistent postnasal drip
Facial fullness (rather than sharp pain)
Decreased or absent sense of smell
Fatigue and low-grade discomfort
No or minimal fever
โ ๏ธ Red Flag Symptoms (Seek urgent care):
Swelling around eyes
Visual changes or double vision
Severe frontal headache with neck stiffness (may suggest spread to CNS)
Altered consciousness or seizures (rare complication)
๐น DIAGNOSIS OF SINUSITIS
Diagnosis is based on clinical history, physical examination, and, in some cases, imaging or laboratory tests.
โ 1. Clinical Diagnosis (Primary Method)
Based on signs and symptoms lasting:
>10 days without improvement (suggests bacterial sinusitis)
Severe symptoms with high fever + purulent discharge for โฅ3โ4 days
Tenderness over sinuses on palpation (e.g., cheeks or forehead)
Transillumination test (less used now): dim light shone over sinus โ dullness suggests fluid
โ 2. Nasal Endoscopy
In-office procedure using a flexible or rigid scope
Allows direct visualization of:
Sinus openings
Polyps
Purulent discharge
Useful in chronic or recurrent cases
โ 3. Imaging (If Needed)
Test
Use
CT Scan (Sinus CT without contrast)
Gold standard in chronic or complicated cases; shows mucosal thickening, sinus opacification, obstruction
X-ray of sinuses
Less sensitive; may show air-fluid levels or opacity
MRI
Reserved for suspected tumors or complications (e.g., orbital or brain spread)
โ 4. Laboratory Tests
Nasal swab for culture: rarely done but useful in recurrent or resistant cases
CBC: may show elevated WBC count in bacterial sinusitis
Allergy testing: if allergic rhinosinusitis is suspected
๐น A. MEDICAL MANAGEMENT
Medical treatment depends on whether the sinusitis is acute, chronic, viral, or bacterial in origin.
โ 1. Supportive/Symptomatic Treatment
(Often used in mild or viral cases)
Measure
Purpose
Rest and hydration
Helps the body fight infection and keeps mucus thin
Warm compresses to the face
Relieves facial pain and pressure
Steam inhalation or humidified air
Opens sinuses and eases breathing
Saline nasal sprays or rinses (neti pot)
Clears mucus and allergens from nasal passages
Decongestants (nasal or oral)
Reduces nasal swelling and opens sinus passages (e.g., Xylometazoline, Oxymetazoline โ use <5 days)
Analgesics/Antipyretics
Relieves headache, facial pain, and fever (e.g., Paracetamol, Ibuprofen)
Antihistamines
Helpful if sinusitis is allergy-related (e.g., Cetirizine, Loratadine)
โ 2. Antibiotic Therapy
(Only for suspected or confirmed bacterial sinusitis)
๐ Indications:
Symptoms >10 days without improvement
Severe symptoms (fever >102ยฐF, purulent discharge, facial pain)
Symptoms worsen after initial improvement (“double worsening”)
Antibiotic
Duration
Notes
Amoxicillin-clavulanate
5โ10 days
First-line choice
Doxycycline
5โ7 days
For penicillin-allergic patients
Azithromycin or Clarithromycin
5 days
Alternative in allergy
Cefixime/Cefuroxime
5โ10 days
Broad-spectrum cephalosporins
โ Avoid overuse of antibiotics in viral sinusitis.
โ 3. Treatment for Chronic Sinusitis
May involve longer antibiotic course (3โ4 weeks)
Intranasal corticosteroids (e.g., Fluticasone, Mometasone) to reduce inflammation
Leukotriene inhibitors in allergy-related cases
Antifungal therapy if fungal sinusitis is diagnosed (e.g., Itraconazole)
๐น B. SURGICAL MANAGEMENT
Surgery is considered for chronic, recurrent, or complicated sinusitis not responding to medical therapy.
โ Indications for Surgery:
Chronic sinusitis unresponsive to โฅ3 months of medical treatment
Recurrent acute sinusitis (โฅ4 episodes/year)
Presence of nasal polyps
Obstruction from deviated septum or anatomical abnormality
Sinus fungal ball or allergic fungal sinusitis
Orbital or intracranial complications
Suspicion of malignancy
โ Surgical Procedures
Procedure
Description
Functional Endoscopic Sinus Surgery (FESS)
Minimally invasive; opens blocked sinuses and restores drainage
Septoplasty
Corrects deviated nasal septum to improve airflow and sinus drainage
Polypectomy
Removal of nasal polyps that obstruct sinus passages
Balloon Sinuplasty
Expands sinus openings using a balloon catheter; less invasive
Caldwell-Luc operation(rare now)
Open procedure for maxillary sinus drainage, used for tumors or severe infections
โ Postoperative Nursing Care
Monitor for bleeding or infection
Educate about saline irrigation after surgery
Avoid nose blowing, heavy lifting, or bending forward for several days
Administer prescribed nasal sprays or antibiotics
Schedule follow-up for nasal endoscopy or debridement
๐ก NURSING MANAGEMENT OF SINUSITIS
๐น A. NURSING ASSESSMENT
โ Subjective Data:
Reports of facial pain or pressure
Nasal congestion or discharge
Headache, worse when bending forward
Postnasal drip, sore throat
Tooth pain (esp. in upper jaw)
History of frequent colds, allergies, or recent infections
โ Objective Data:
Swelling/tenderness over sinuses (frontal, maxillary)
Nasal mucosa may appear red and swollen
Thick yellow/green nasal discharge
Mild to moderate fever
Fatigue or malaise
๐น B. COMMON NURSING DIAGNOSES
Nursing Diagnosis
Related To
Evidenced By
Acute pain
Sinus pressure and inflammation
Facial pain, headache
Ineffective airway clearance
Mucosal swelling and nasal discharge
Nasal congestion, mouth breathing
Hyperthermia
Infection
Fever, flushed skin
Disturbed sleep pattern
Nighttime congestion or pain
Difficulty sleeping
Knowledge deficit
Lack of awareness about sinus care
Misuse of decongestants, poor medication adherence
๐น C. NURSING INTERVENTIONS AND RATIONALES
Interventions
Rationale
Assess and document location and severity of sinus pain
Helps determine the affected sinus and monitor response
Encourage steam inhalation or humidified air
Loosens secretions and eases sinus drainage
Administer analgesics and antipyretics as prescribed
Relieves pain and controls fever
Instruct on proper use of saline nasal spray or rinse
Promotes sinus drainage and removes allergens
Apply warm compresses over the sinuses
Reduces swelling and relieves pain
Encourage oral fluids
Thins mucus and prevents dehydration
Teach patient to avoid nose blowing forcefully
Prevents further irritation or pressure buildup
Administer antibiotics or nasal steroids as prescribed
Treats infection and reduces inflammation
Position patient with head elevated during rest
Enhances sinus drainage and relieves pressure
Educate patient to complete full course of antibiotics
Prevents relapse and resistance
๐น D. PATIENT AND FAMILY EDUCATION
Complete all prescribed medications even if symptoms improve
Use steam inhalation or warm compresses 2โ3 times daily
Maintain hydration and avoid caffeine or alcohol (which can cause dehydration)
Avoid exposure to dust, smoke, and allergens
Do not overuse nasal decongestants (limit to <5 days) to prevent rebound congestion
Blow nose gently, one nostril at a time
Perform saline irrigation correctly and hygienically
Seek medical attention if:
Fever persists >3 days
Vision changes or eye swelling occurs
Symptoms worsen after initial improvement
๐น E. EVALUATION
Patient reports relief of facial pain and congestion
Nasal discharge reduced or resolved
Patient demonstrates correct sinus care practices
No signs of complications (e.g., orbital cellulitis, abscess)
Patient completes full course of medications without side effects
โ ๏ธ COMPLICATIONS OF SINUSITIS
While most sinusitis cases are mild and self-limiting, untreated or chronic sinusitis may lead to serious complications, especially in bacterial or immunocompromised cases.
๐น 1. Orbital Cellulitis
Infection spreads to the eye socket
Causes eye swelling, redness, pain, and restricted movement
May lead to vision loss if untreated
๐น 2. Abscess Formation
Subperiosteal abscess, orbital abscess, or brain abscess
Severe headache, neurological symptoms, or visual changes
Septoplasty or Polypectomy if structural obstruction present
โ๏ธ Nursing Role:
Symptom monitoring, pain management
Educate on steam inhalation, nasal care, medication adherence
Monitor for signs of complications
โ๏ธ Complications:
Orbital cellulitis
Meningitis
Chronic sinusitis
Brain abscess
Osteomyelitis
Asthma flare-up
๐ OTITIS MEDIA
(Middle Ear Infection)
๐น DEFINITION
Otitis media is the inflammation or infection of the middle ear, which lies behind the eardrum and contains the ossicles (malleus, incus, and stapes). It is commonly caused by bacteria or viruses and is especially frequent in infants and young children.
There are several types:
Acute Otitis Media (AOM): Sudden onset with signs of infection
Otitis Media with Effusion (OME): Fluid in the middle ear without signs of active infection
Chronic Suppurative Otitis Media (CSOM): Persistent infection with ear discharge and possible perforation
Upper respiratory tract infections (especially in children)
Eustachian tube dysfunction (shorter and more horizontal in children)
Allergic rhinitis or sinusitis
Bottle-feeding while lying down
Exposure to tobacco smoke
Adenoid hypertrophy
Poor air quality or crowded living conditions
Cleft palate or craniofacial abnormalities
๐น PATHOPHYSIOLOGY OF OTITIS MEDIA
Triggering Event: Begins with an upper respiratory tract infection, allergy, or exposure to irritants โ leads to nasal and nasopharyngeal mucosal inflammation.
Eustachian Tube Dysfunction:
Inflammation or blockage causes impaired ventilation and drainage of the middle ear.
This creates negative pressure, pulling fluid into the middle ear.
Accumulation of Fluid:
Mucus or serous fluid collects behind the eardrum.
This provides a medium for bacterial or viral growth.
Infection and Inflammation:
Infective agents multiply โ inflammatory response leads to:
Redness and bulging of the tympanic membrane (eardrum)
Pain due to pressure
Fever and irritability
Possible Outcomes:
Resolution with immune response or antibiotics
Tympanic membrane rupture โ drainage of pus (otorrhea)
Progression to chronic infection or complications like mastoiditis
๐น SIGN AND SYMPTOMS
Symptoms of Otitis Media vary depending on the type (Acute, with Effusion, or Chronic). It is particularly common and sometimes harder to detect in infants and young children.
โ A. Acute Otitis Media (AOM)
(Acute infection of the middle ear with fluid buildup)
Symptom
Description
Ear pain (otalgia)
Most common complaint; sudden and sharp in nature
Fever
Usually mild to moderate (may go up to 102โ104ยฐF)
Hearing loss or muffled hearing
Due to fluid blocking sound conduction
Ear fullness or pressure
Sensation of blockage
Irritability and excessive crying (in children)
Due to pain and discomfort
Poor feeding or disturbed sleep
Especially in infants
Tugging or pulling at the ear
Common sign in babies/toddlers
Nasal congestion or cold symptoms
Often precede the ear infection
Nausea or vomiting
In children, due to inner ear involvement or fever
Ear discharge (otorrhea)
If tympanic membrane ruptures, there may be drainage of pus or fluid from the ear
โ B. Otitis Media with Effusion (OME)
(Fluid in the middle ear without acute infection)
Symptom
Description
Hearing difficulty
Most prominent sign; can lead to speech delay in children
Ear fullness
Feeling of blockage, especially after colds
No pain or fever
Distinguishes it from acute infection
May be asymptomatic
Detected during routine exam or hearing check
โ C. Chronic Suppurative Otitis Media (CSOM)
(Persistent or recurring ear infection with perforation)
Symptom
Description
Persistent or recurrent ear discharge (otorrhea)
Foul-smelling, may be pus-like
Hearing loss
Due to tympanic membrane damage or ossicle involvement
Perforated tympanic membrane
May be seen on otoscopic exam
No pain or fever in many cases
Infection is chronic and low-grade
Vertigo or imbalance(occasionally)
If inner ear is involved
๐น DIAGNOSIS OF OTITIS MEDIA
Diagnosis is primarily clinical, based on history and otoscopic examination. In complicated or chronic cases, audiological and imaging studies may be used.
โ 1. History and Symptom Review
Ask about:
Recent colds or upper respiratory infection
Onset and duration of ear pain
Fever, irritability, discharge
Hearing changes
โ 2. Physical Examination
A. Otoscopy
Main tool for diagnosis
Use an otoscope to visualize the tympanic membrane (eardrum)
Finding
Suggests
Red, bulging tympanic membrane
Acute Otitis Media
Air-fluid levels or bubbles
Otitis Media with Effusion
Dull, immobile tympanic membrane
Fluid buildup
Perforation or pus leakage
Chronic suppurative otitis media
B. Pneumatic Otoscopy
Checks mobility of the tympanic membrane by puffing air
Reduced or absent movement suggests fluid in the middle ear
โ 3. Hearing Assessment
Tuning fork tests (Weber & Rinne): may show conductive hearing loss
Tympanometry: Measures movement of the eardrum โ abnormal in OME
Audiometry: Used in chronic cases or if speech delay is suspected
โ 4. Laboratory Tests (if needed)
Ear discharge culture: For CSOM or recurrent infections
CBC: May show elevated WBC in bacterial infections
โ 5. Imaging (for complications)
CT scan of temporal bone: If mastoiditis, abscess, or cholesteatoma is suspected
๐น A. MEDICAL MANAGEMENT
Medical treatment depends on the type of otitis media, the age of the patient, and the severity of symptoms.
โ 1. Acute Otitis Media (AOM)
๐ธ First-Line Treatment (If bacterial or moderate/severe):
Medication
Purpose
Notes
Amoxicillin (high-dose)
First-line antibiotic
7โ10 days (depending on age/severity)
Amoxicillin-clavulanate
If resistant bacteria suspected or recurrent infection
Alternative to plain amoxicillin
Azithromycin / Cefuroxime
For penicillin allergy
Effective against common pathogens
๐ธ Supportive Care:
Analgesics/Antipyretics (Paracetamol, Ibuprofen): To relieve pain and fever
Decongestants and antihistamines (if URI or allergy present): Used with caution; not first-line in children
Nasal saline drops/sprays: To reduce nasal congestion and Eustachian tube blockage
Warm compress over ear: To relieve localized pain
โ 2. Otitis Media with Effusion (OME)
(No signs of infection; just fluid buildup)
Observation for 3 months if asymptomatic
Autoinflation techniques (e.g., Valsalva maneuver) in older children
Intranasal corticosteroids if allergic component is present
Hearing monitoring โ audiometry recommended if speech delay or school difficulties suspected
Surgery is indicated for recurrent, chronic, or complicated otitis media, especially when hearing loss or structural damage occurs.
โ Indications for Surgery:
Recurrent acute otitis media (โฅ3 episodes in 6 months or โฅ4 in 1 year)
Persistent otitis media with effusion >3 months affecting hearing
Chronic suppurative otitis media (CSOM) with tympanic membrane perforation
Complications: mastoiditis, cholesteatoma, hearing loss
โ Surgical Procedures
Procedure
Description
Indications
Myringotomy
Small incision in the eardrum to drain fluid
Severe AOM with effusion or pain
Tympanostomy tube insertion (Grommets)
Ventilation tubes placed in eardrum
Recurrent AOM or persistent OME
Tympanoplasty
Repair of perforated tympanic membrane
CSOM with hearing loss
Mastoidectomy
Removal of infected mastoid bone
Mastoiditis or cholesteatoma
Adenoidectomy
Removal of adenoids
If adenoids contribute to Eustachian tube dysfunction or recurrent infections
โ Postoperative Nursing Care
Keep ear dry and clean
Monitor for drainage, pain, or bleeding
Administer prescribed antibiotics or eardrops
Educate patient/parents on:
Preventing water entry (no swimming, use earplugs)
Recognizing signs of recurrence or complications
Ensure follow-up for hearing tests
๐ NURSING MANAGEMENT OF OTITIS MEDIA
๐น A. NURSING ASSESSMENT
โ Subjective Data:
Complaint of ear pain (sharp, throbbing)
Hearing difficulty or muffled sounds
History of cold, nasal congestion, or recent upper respiratory infection
Irritability, disturbed sleep, or poor feeding (in infants)
โ Objective Data:
Fever, especially in acute cases
Pulling or rubbing ear (common in children)
Visible ear discharge (in CSOM or perforation)
Redness and bulging tympanic membrane (via otoscopy)
Signs of fluid buildup or decreased tympanic membrane mobility
๐น B. COMMON NURSING DIAGNOSES
Nursing Diagnosis
Related To
Evidenced By
Acute pain
Inflammation and pressure in middle ear
Patient reports ear pain, child is irritable
Hyperthermia
Infection process
Elevated body temperature
Disturbed sensory perception (auditory)
Fluid accumulation or tympanic damage
Hearing difficulty, inattentiveness
Risk for infection spread
Untreated or chronic infection
Persistent ear discharge, fever
Knowledge deficit
Lack of awareness about ear care
Inappropriate ear cleaning, medication misuse
๐น C. NURSING INTERVENTIONS AND RATIONALES
Nursing Interventions
Rationale
Assess location, severity, and nature of ear pain
Helps evaluate effectiveness of treatment
Monitor vital signs, especially temperature
Detects fever and early signs of systemic infection
Administer analgesics/antipyretics (e.g., Paracetamol) as prescribed
Relieves pain and reduces fever
Keep ear clean and dry; avoid inserting objects into ear
Prevents trauma and secondary infection
Apply warm compress to affected ear
Provides comfort and reduces pain
Administer antibiotics or ear drops as prescribed
Treats bacterial infection; ensure full course
Encourage child to rest in upright position
Improves ear drainage and reduces pain
Teach proper ear hygiene and safe nose blowing
Prevents pressure buildup and spreading of infection
Educate parents to avoid bottle feeding in supine position
Reduces risk of Eustachian tube blockage in infants
Emphasize follow-up visits for ear exam or hearing assessment
Monitors treatment success and prevents complications
๐น D. PATIENT AND FAMILY EDUCATION
Complete the full course of antibiotics, even if symptoms improve
Avoid getting water into ears โ use earplugs if needed
Do not insert cotton buds, pins, or other objects into the ear
Recognize signs of worsening:
Persistent fever
Increased ear discharge
Hearing loss
Swelling around the ear or face
Encourage vaccination (e.g., pneumococcal, influenza) to prevent URTIs
Inform about the importance of hearing monitoring in recurrent cases, especially in children
๐น E. EVALUATION CRITERIA
Patient reports relief from ear pain
Temperature is normal
Ear discharge has resolved or decreased
No signs of complications (e.g., mastoiditis, hearing loss)
Patient and family demonstrate understanding of ear care and prevention strategies
โ ๏ธ COMPLICATIONS OF OTITIS MEDIA
While most cases of Otitis Media resolve with treatment, untreated or recurrent infections may lead to serious local, regional, or systemic complications.
๐น 1. Hearing Loss
Most common complication, especially in Otitis Media with Effusion (OME) or Chronic Suppurative Otitis Media (CSOM)
Can affect speech and language development in children
๐น 2. Tympanic Membrane Perforation
Due to pressure buildup or infection
May result in ear discharge (otorrhea) and hearing impairment
Can be temporary or persistent
๐น 3. Mastoiditis
Infection of the mastoid bone behind the ear
Symptoms: ear pain, swelling behind the ear, fever, tenderness
Requires IV antibiotics or mastoidectomy (surgery)
๐น 4. Cholesteatoma
Abnormal skin growth in the middle ear due to chronic infection
Leads to bone destruction, hearing loss, and risk of serious complications
๐น 5. Labyrinthitis
Infection spreads to the inner ear, causing vertigo, dizziness, hearing loss, and nausea
๐น 6. Facial Nerve Paralysis
Inflammation or pressure affects cranial nerve VII (facial nerve)
Leads to muscle weakness on one side of the face
๐น 7. Meningitis
Infection spreads to the meninges (brain covering)
Life-threatening complication
Presents with headache, neck stiffness, altered consciousness
๐น 8. Brain Abscess
Rare but serious complication of chronic or untreated infection
Requires urgent neurosurgical intervention
โ KEY POINTS ON OTITIS MEDIA
โ๏ธ Definition: Inflammation or infection of the middle ear, commonly seen in infants and young children
โ๏ธ Types:
Acute Otitis Media (AOM) โ rapid onset, pain, fever
Otitis Media with Effusion (OME) โ fluid without infection
Chronic Suppurative Otitis Media (CSOM) โ long-term discharge and perforation
Epiglottitis is a rapidly progressing inflammation of the epiglottis โ the flap of cartilage located at the base of the tongue, which prevents food from entering the trachea (windpipe) during swallowing.
It is a medical emergency, especially in children, as swelling can block the airway, causing respiratory distress or sudden death.
Can occur in both children and adults, but more common and severe in children aged 2 to 6 years.
๐น CAUSES OF EPIGLOTTITIS
โ 1. Infectious Causes (Most Common)
Pathogen
Notes
Haemophilus influenzae type B (Hib)
Most common cause in children before widespread Hib vaccination
Streptococcus pneumoniae
Common in adults
Group A Streptococcus (Strep pyogenes)
Can cause rapidly progressing infection
Staphylococcus aureus (including MRSA)
May cause severe infection
Viruses
Occasionally involved (e.g., varicella, HSV)
โ 2. Non-Infectious / Traumatic Causes
Cause
Description
Thermal injury
Inhalation of hot steam or ingestion of hot fluids
Chemical injury
Caustic substances or foreign body
Allergic reactions
Rare, but can cause angioedema involving the epiglottis
Post-intubation
Mechanical trauma to the epiglottis from endotracheal tubes
๐น PATHOPHYSIOLOGY OF EPIGLOTTITIS
Pathogen Entry or Trauma
Bacteria or other irritants enter via the upper airway
Infection targets the epiglottis and surrounding supraglottic structures
Acute Inflammatory Response
Immune system releases cytokines, causing vasodilation and capillary leakage
Leads to rapid swelling of the epiglottis and aryepiglottic folds
Airway Obstruction Risk
Swollen epiglottis may prolapse backward, obstructing the laryngeal inlet
Causes inspiratory stridor, labored breathing, and respiratory distress
Rapid Progression in Children
Narrower airways in children mean even minor swelling can cause complete obstruction
Can progress to hypoxia, cyanosis, respiratory failure, and death if not managed urgently
โ ๏ธ Why It’s an Emergency
Swelling of the epiglottis can block airflow to the lungs
The child or adult can suffocate rapidly without prompt airway management and antibiotics
๐น SIGN AND SYMPTOMS
Epiglottitis symptoms appear suddenly and progress rapidly, especially in children. Early recognition is critical to prevent airway obstruction.
โ Classic Signs and Symptoms in Children
(โ4 Ds + stridorโ)
Symptom
Description
Dysphagia
Difficulty swallowing
Drooling
Inability to swallow saliva due to throat swelling
Sitting upright, leaning forward, chin thrust out โ to ease breathing
Tachypnea, tachycardia
Signs of respiratory distress
Cyanosis (late sign)
Indicates hypoxia and impending respiratory failure
๐ง Remember: In young children, do not attempt to examine the throat with a tongue depressor unless airway support is ready โ it can trigger complete airway obstruction.
โ Symptoms in Adults
Sore throat (often severe, out of proportion to visible findings)
Hoarseness or voice changes
Painful swallowing
Fever and chills
Drooling and stridor (less common than in children)
Often misdiagnosed as pharyngitis or laryngitis in early stages
๐น DIAGNOSIS OF EPIGLOTTITIS
Prompt diagnosis is critical and based on clinical signs, supported by imaging or direct visualization only in a controlled setting (e.g., OR or ICU with airway equipment ready).
โ 1. Clinical Diagnosis (First and most important)
Based on sudden onset of sore throat, drooling, difficulty swallowing, stridor
Look for tripod posture, labored breathing, and muffled voice
Avoid delay in treatment for unnecessary tests
โ 2. Lateral Neck X-ray (Soft Tissue X-ray)
Performed only if the airway is stable
Shows “thumb sign” โ swollen epiglottis appears like a thumb-shaped shadow
Not needed if diagnosis is obvious and airway is compromised
โ 3. Direct Visualization (Laryngoscopy or Bronchoscopy)
Gold standard but only done in OR or ICU with full airway management team
Reveals red, swollen, cherry-red epiglottis
Risky in children unless intubation equipment is ready
โ 4. Laboratory Tests
Test
Purpose
CBC
May show leukocytosis (elevated WBCs)
Blood cultures
To identify the causative organism (e.g., H. influenzae)
Throat cultures
Usually avoided unless airway is secure
โ Important: Never delay airway protection for diagnostic tests in suspected epiglottitis. Airway assessment and securing it is the top priority.
๐น A. MEDICAL MANAGEMENT
The primary goals are:
Securing the airway
Treating the infection
Reducing inflammation
Preventing complications
โ 1. Airway Management โ First and Most Critical Step
Action
Rationale
Keep patient calm and in sitting position
Anxiety can worsen airway obstruction
Avoid throat examination in children unless in a controlled setting
Prevents triggering complete airway blockage
Prepare for emergency intubation or tracheostomy
Must be done early before complete obstruction occurs
Admit to ICU or high-dependency unit
For continuous monitoring and airway management readiness
๐ Never leave a patient with suspected epiglottitis unattended or delay airway intervention.
โ 2. Oxygen Therapy
Administer humidified oxygen via face mask
Avoid forcing oxygen masks in children; use blow-by technique if needed
โ 3. Antibiotic Therapy
(Empiric IV antibiotics started immediately after cultures are taken)
Antibiotic
Purpose
Ceftriaxone or Cefotaxime
Broad-spectrum third-generation cephalosporins
Ampicillinโsulbactam or Amoxicillinโclavulanate
For coverage of H. influenzae, Streptococcus, Staphylococcus
Vancomycin
Added if MRSA is suspected
Duration: Usually 7โ10 days; IV initially, then switch to oral once stable
โ 4. Corticosteroids(optional/controversial)
Dexamethasone or methylprednisolone may be used to reduce airway edema
Not a substitute for airway management โ used as adjunct
โ 5. Antipyretics and Analgesics
Paracetamol or ibuprofen for fever and pain relief
๐น B. SURGICAL MANAGEMENT
Surgical intervention is mainly focused on airway protection in cases of severe obstruction.
โ 1. Endotracheal Intubation
(Preferred method for airway protection)
Details
Notes
Performed in OR or ICU with anesthetist and ENT backup
Ensures safety and readiness for complications
Use of smaller diameter endotracheal tubes
To accommodate inflamed airway
Duration: Typically 2โ3 days until swelling subsides
โ 2. Tracheostomy
(Done if intubation fails or is not possible)
Indication
Notes
Severe swelling or complete obstruction
Surgical opening made in trachea
Life-saving procedure
Done under local anesthesia in emergency
โ 3. Surgical Abscess Drainage
In rare cases where a periepiglottic or deep neck abscess forms
Requires ENT surgical intervention
โ 4. Post-Airway Management
Maintain patient in ICU for monitoring
Gradually wean off intubation as swelling resolves
Repeat laryngoscopy before extubation to ensure airway patency
Resume oral intake once swallowing is safe
๐ด NURSING MANAGEMENT OF EPIGLOTTITIS
๐น A. NURSING ASSESSMENT
โ Subjective Data:
Reports of severe sore throat
Difficulty swallowing (dysphagia)
Complaints of breathing difficulty
History of recent upper respiratory infection
โ Objective Data:
High fever
Drooling, muffled voice, stridor
Child sitting in tripod position (upright, leaning forward)
Anxiety, restlessness, tachypnea
No spontaneous cough (differentiates from croup)
โ ๏ธ DO NOT use a tongue depressor to examine the throat in children unless airway support is immediately available โ it may trigger complete airway blockage.
๐น B. NURSING DIAGNOSES
Nursing Diagnosis
Related To
Evidenced By
Ineffective airway clearance
Inflammation and edema of the epiglottis
Stridor, labored breathing, drooling
Impaired gas exchange
Obstructed upper airway
Cyanosis, tachypnea, anxiety
Acute pain
Inflammation of throat structures
Reports of sore throat, irritability
Risk for aspiration
Inability to swallow secretions
Drooling, dysphagia
Anxiety (child and caregiver)
Acute illness and breathing difficulty
Restlessness, fear, caregiver distress
๐น C. NURSING INTERVENTIONS AND RATIONALES
Nursing Interventions
Rationale
Ensure emergency airway equipment is at bedside (intubation tray, tracheostomy kit, oxygen)
To respond immediately if airway obstruction occurs
Administer humidified oxygen (preferably blow-by)
Enhances oxygenation without distressing the patient
Keep the child in a position of comfort (usually tripod position)
Reduces work of breathing and optimizes airway patency
Avoid any procedure that may upset the child (e.g., IV insertion without need)
Crying and agitation may worsen obstruction
Monitor for signs of respiratory distress (retractions, nasal flaring, cyanosis)
Early detection of airway compromise
Administer prescribed IV antibiotics and corticosteroids
Treats infection and reduces airway swelling
Ensure NPO (nothing by mouth) until airway is secured and swallowing is assessed
Prevents aspiration and choking
Stay with the patient at all times
Provides emotional support and ensures immediate response if condition deteriorates
Educate caregivers about the condition and management
Helps reduce anxiety and improve cooperation
Arrange ICU transfer if not already in ICU
For close monitoring and potential intubation
๐น D. PATIENT & FAMILY EDUCATION
Do not attempt to examine the childโs throat at home
Importance of completing antibiotic course
Recognize early signs of breathing difficulty (stridor, drooling, voice changes)
Encourage Hib vaccination to prevent recurrence
Reassure parents and explain the care plan step-by-step
๐น E. EVALUATION
Airway remains clear and unobstructed
Oxygen saturation maintained >95%
Child is calm, less anxious, and fever is reduced
No aspiration or respiratory arrest occurs
Parents/caregivers demonstrate understanding of condition and emergency signs
๐ด COMPLICATIONS OF EPIGLOTTITIS
Epiglottitis is a medical emergency because it can rapidly block the airway and lead to life-threatening complications.
Barrel chest (in emphysema), cyanosis (in bronchitis)
Fatigue and weight loss
โ๏ธ Diagnosis:
Spirometry (FEVโ/FVC < 70%)
Chest X-ray/CT, ABG, 6-minute walk test
โ๏ธ Medical Management:
Smoking cessation
Inhaled bronchodilators (SABA, LABA, LAMA)
Inhaled corticosteroids
Oxygen therapy for hypoxemia
Pulmonary rehabilitation
โ๏ธ Surgical Options:
Lung volume reduction
Bullectomy
Lung transplant (severe cases)
โ๏ธ Nursing Care Includes:
Monitoring oxygen levels
Teaching breathing techniques
Promoting energy conservation and proper inhaler use
Encouraging nutrition and infection prevention
Providing emotional support
โ๏ธ Complications:
Exacerbations, respiratory failure, cor pulmonale, pneumothorax, depression, lung cancer
๐ต PLEURAL EFFUSION
๐น DEFINITION
Pleural effusion is the abnormal accumulation of fluid in the pleural space โ the thin cavity between the visceral and parietal pleura that surrounds the lungs.
Normally, 5โ15 mL of lubricating fluid is present in the pleural space.
In pleural effusion, this volume increases significantly, causing lung compression, impaired gas exchange, and dyspnea.
๐น TYPES OF PLEURAL EFFUSION
Type
Description
Transudative
Clear, low-protein fluid due to imbalance in hydrostatic/oncotic pressure
Exudative
Cloudy, protein-rich fluid due to inflammation or infection
Empyema
Pus in pleural space (infected effusion)
Hemothorax
Blood accumulation in the pleural space
Chylothorax
Lymphatic fluid (chyle) in the pleural cavity due to lymphatic obstruction or trauma
๐น CAUSES OF PLEURAL EFFUSION
โ 1. Transudative Effusion (Systemic Causes)
Cause
Mechanism
Congestive heart failure (most common)
โ Hydrostatic pressure
Cirrhosis with ascites
โ Oncotic pressure due to hypoalbuminemia
Nephrotic syndrome
Loss of protein โ โ plasma oncotic pressure
Pulmonary embolism (some cases)
Can cause both transudate or exudate
Peritoneal dialysis
Fluid may migrate into pleural space
โ 2. Exudative Effusion (Local Causes)
Cause
Mechanism
Pneumonia (parapneumonic effusion)
Inflammation of pleura causes leakage of protein-rich fluid
Patient and family demonstrate understanding of care and follow-up
๐ต COMPLICATIONS OF PLEURAL EFFUSION
While small pleural effusions may resolve with treatment of the underlying cause, large or untreated effusions can lead to serious, sometimes life-threatening complications.
๐น 1. Respiratory Distress or Failure
Due to lung compression, reduced gas exchange
More common in large or bilateral effusions
๐น 2. Lung Collapse (Atelectasis)
Fluid prevents full expansion of the lung, causing partial or complete collapse
๐น 3. Empyema
Infected pleural effusion with pus accumulation
Requires antibiotics and chest tube drainage
๐น 4. Sepsis
Infection from empyema or pneumonia may enter bloodstream, leading to septic shock
๐น 5. Fibrothorax
Chronic inflammation may lead to fibrosis of the pleural space, restricting lung expansion
๐น 6. Re-expansion Pulmonary Edema
Occurs when large volume of fluid is removed too rapidly
Can cause acute respiratory failure โ requires careful drainage planning
๐น 7. Pneumothorax (Collapsed Lung)
Accidental puncture during thoracentesis or tube insertion may allow air into pleural space
๐น 8. Recurrence of Effusion
Especially common in malignancy, cirrhosis, or heart failure
May need pleurodesis or long-term drainage solutions
โ KEY POINTS ON PLEURAL EFFUSION
โ๏ธ Definition: Abnormal collection of fluid in the pleural space
Empyema is the accumulation of pus in the pleural space, the cavity between the visceral and parietal pleura surrounding the lungs. It is usually a complication of pneumonia or chest infections, where the infection spreads to the pleural cavity.
It is a type of exudative pleural effusion, but distinguished by the presence of purulent (infected) fluid.
Empyema is a medical emergency that requires prompt drainage and antibiotic therapy.
๐น CAUSES OF EMPYEMA
Empyema is usually caused by bacterial infection, but may also occur due to trauma, surgery, or other diseases.
Bronchiectasis is a chronic, irreversible condition characterized by permanent abnormal dilation and destruction of the bronchi and bronchioles, resulting in chronic infection, inflammation, and impaired mucus clearance.
Leads to accumulation of mucus, recurrent infections, and progressive airway damage.
Affects one or more lung segments, often bilateral in severe cases.
๐น CAUSES OF BRONCHIECTASIS
Bronchiectasis may be congenital or acquired, and often results from recurrent or severe respiratory infections.
โ 1. Post-Infectious Causes(most common)
Infection
Examples
Bacterial pneumonia
Staphylococcus aureus, Klebsiella, Pseudomonas
Tuberculosis
Causes localized bronchiectasis
Measles, Pertussis (whooping cough)
In children, may damage airways
Fungal infections
Aspergillus (especially in ABPA)
โ 2. Obstructive Causes
Type
Description
Foreign body aspiration
Leads to localized airway obstruction and infection
Most common inherited cause; thick secretions lead to chronic infection
Primary Ciliary Dyskinesia
Defective cilia โ poor mucus clearance
Kartagenerโs Syndrome
Triad: bronchiectasis, chronic sinusitis, situs inversus
โ 4. Immune Deficiency Disorders
Example
Impact
IgA deficiency, HIV
Impaired host defense โ chronic infections
โ 5. Allergic and Inflammatory Disorders
Disorder
Relevance
Allergic bronchopulmonary aspergillosis (ABPA)
Hypersensitivity to Aspergillus โ mucus plugging and inflammation
Rheumatoid arthritis, Sjรถgrenโs syndrome
Autoimmune airway inflammation
โ 6. Miscellaneous Causes
Chronic aspiration
Inhalation injuries (chemical, smoke)
Idiopathic (no identifiable cause in up to 50% of non-CF cases)
๐น PATHOPHYSIOLOGY OF BRONCHIECTASIS
Initial Insult or Infection
Triggers inflammation of the bronchial wall.
Causes mucosal damage, impaired ciliary function, and mucus accumulation.
Cycle of Infection and Inflammation
Mucus stagnation allows bacterial overgrowth.
Leads to recurrent infections and further tissue destruction.
Bronchial Wall Damage
Chronic inflammation causes:
Thickening and scarring
Destruction of elastic and muscular components of bronchial walls
Permanent dilation of airways
Impaired Mucociliary Clearance
Cilia are damaged or absent
Thick mucus becomes difficult to expel โ persistent cough and sputum
Vicious Cycle
Infection โ inflammation โ damage โ more infection
Progressive airflow obstruction and loss of lung function
Types of Bronchiectasis(Based on CT Imaging): | Type | Description | |——|————-| | Cylindrical | Uniform dilation of airways (most common) | | Varicose | Irregular, beaded appearance | | Cystic (saccular) | Severe, ballooned dilations with air-fluid levels |
๐น SIGN AND SYMPTOMS
The symptoms of bronchiectasis are typically chronic, progressive, and related to mucus accumulation, infection, and airway obstruction. The severity depends on the extent and location of the disease.
โ Common Signs & Symptoms
Symptom
Description
Chronic productive cough
Persistent cough with daily production of large amounts of sputum (often foul-smelling)
Purulent (thick, green/yellow) sputum
Especially during exacerbations
Recurrent respiratory infections
Frequent episodes of bronchitis or pneumonia
Hemoptysis
Blood in sputum due to inflamed or eroded bronchial vessels
Dyspnea (shortness of breath)
Especially on exertion; worsens with disease progression
Wheezing or crackles
Heard on auscultation (coarse crepitations over affected areas)
Fatigue and weight loss
Due to chronic illness and inflammation
Clubbing of fingers
Long-term sign of chronic hypoxia and inflammation
Chest pain
May occur with infections or pleuritic involvement
โ Symptoms of Underlying Conditions May Be Present
Immunodeficiency: Frequent infections in other systems as well
๐น DIAGNOSIS OF BRONCHIECTASIS
Early diagnosis is key to managing symptoms and preventing progression. Diagnosis involves clinical history, physical examination, imaging, and lab tests.
โ 1. Clinical Evaluation
History of chronic productive cough, frequent respiratory infections
Assess for childhood illnesses, TB, asthma, or CF
Listen for crackles or coarse rhonchi on auscultation
Pneumonia is an acute infection or inflammation of the lung parenchyma, specifically the alveoli and surrounding tissues, leading to accumulation of fluid or pus in the alveolar sacs.
It results in impaired gas exchange, cough, fever, difficulty breathing, and chest pain.
Pneumonia may affect one or both lungs (unilateral or bilateral) and can range from mild to life-threatening.
๐น TYPES OF PNEUMONIA
Type
Based On
Community-Acquired Pneumonia (CAP)
Acquired outside hospitals
Hospital-Acquired Pneumonia (HAP)
Occurs โฅ48 hrs after hospital admission
Ventilator-Associated Pneumonia (VAP)
Occurs โฅ48 hrs after endotracheal intubation
Aspiration Pneumonia
Inhalation of food, fluid, or vomit into lungs
Atypical Pneumonia
Caused by organisms like Mycoplasma, Chlamydia, Legionella
Perform chest physiotherapy or postural drainage if ordered
Aids in mobilizing secretions
Promote rest and energy conservation
Prevents fatigue and aids recovery
Maintain infection control practices (hand hygiene, mask use)
Prevents spread of infection to others
๐น D. PATIENT & FAMILY EDUCATION
Explain the disease process and importance of completing antibiotics
Teach effective coughing techniques and deep breathing exercises
Demonstrate use of inhalers or nebulizers if prescribed
Encourage increased fluid intake to help loosen mucus
Educate on importance of vaccination:
Pneumococcal and Influenza vaccine for prevention
Instruct on recognizing early signs of worsening:
Increased shortness of breath
High fever
Purulent sputum
Chest pain
Encourage follow-up care and adherence to treatment plan
๐น E. EVALUATION CRITERIA
Patient maintains SpOโ โฅ 92% on room air or prescribed oxygen
Patient demonstrates effective coughing and clear lung sounds
Reports relief of chest pain and absence of fever
Sputum characteristics improve (less purulent and reduced volume)
Patient verbalizes understanding of medication regimen and preventive strategies
No signs of complications such as respiratory failure or sepsis
โ ๏ธ COMPLICATIONS OF PNEUMONIA
If untreated or poorly managed, pneumonia can lead to serious and life-threatening complications, especially in vulnerable groups (elderly, immunocompromised, infants).
๐น 1. Respiratory Failure
Due to impaired gas exchange from alveolar fluid and consolidation
May require oxygen therapy or mechanical ventilation
๐น 2. Pleural Effusion
Fluid accumulation in the pleural space
May need thoracentesis for diagnosis/treatment
๐น 3. Empyema
Pus in the pleural cavity (infected pleural effusion)
Requires chest tube drainage and antibiotics
๐น 4. Lung Abscess
Localized pus collection in lung tissue
Manifests as persistent fever, foul-smelling sputum
Pneumococcal and influenza vaccines, hand hygiene, timely treatment of infections
๐ด LUNG ABSCESS
๐น DEFINITION
A lung abscess is a localized area of necrosis and pus formation (suppuration) within the lung tissue, leading to the formation of a cavity filled with pus, bacteria, and cellular debris.
It is usually caused by a severe infection in the lungs.
Typically seen as a thick-walled cavity with an air-fluid level on imaging.
May be acute (<6 weeks) or chronic (>6 weeks).
๐น CAUSES OF LUNG ABSCESS
Lung abscesses are commonly caused by bacterial infection, often following aspiration, and less commonly by fungal or parasitic infections.
โ 1. Aspiration (Most Common Cause)
Aspiration of oropharyngeal or gastric contents (food, saliva, vomitus) into the lungs, especially in:
Alcoholics
Elderly or debilitated patients
Patients with seizures or altered consciousness
Post-stroke patients
Those with poor dental hygiene
Common organisms: Anaerobes, Streptococcus, Klebsiella, Staphylococcus aureus
โ 2. Post-Pneumonia (Secondary Infection)
Complication of severe or necrotizing pneumonia
Common organisms:
Staphylococcus aureus
Klebsiella pneumoniae
Pseudomonas aeruginosa
โ 3. Bronchial Obstruction
Tumors or foreign body causing airway blockage, leading to infection and necrosis
โ 4. Hematogenous Spread
Bacteria from another site (e.g., infective endocarditis) spreads to lungs via bloodstream
โ 5. Immunocompromised Conditions
HIV/AIDS, cancer, diabetes, organ transplant recipients
More susceptible to fungal, parasitic, or unusual bacterial infections
๐น PATHOPHYSIOLOGY OF LUNG ABSCESS
Entry of Pathogen
Microorganisms (mainly anaerobic bacteria) enter the lung by aspiration or spread.
Local Infection and Inflammation
Lung parenchyma becomes inflamed.
Neutrophils and immune cells invade the site to fight infection.
Tissue Necrosis
Bacterial enzymes and toxins, along with immune response, cause destruction (necrosis) of lung tissue.
Cavitation
As lung tissue breaks down, a cavity forms in the affected area.
The cavity fills with pus, dead cells, and debris.
Walling Off (Encapsulation)
A fibrous wall forms around the abscess cavity.
The abscess may drain into bronchi, resulting in foul-smelling sputum.
Healing or Complication
With treatment, the abscess may heal by fibrosis.
Without treatment, it may rupture into pleura, cause empyema, sepsis, or bronchopleural fistula.
๐น SIGN AND SYMPTOMS
The clinical features of a lung abscess develop gradually over days to weeks and are primarily due to lung tissue necrosis, inflammation, and infection.
โ 1. Respiratory Symptoms
Symptom
Description
Persistent productive cough
Main symptom; worsens over time
Foul-smelling, purulent sputum
Often copious and offensive due to anaerobic infection
Hemoptysis
Blood-streaked sputum or frank bleeding from eroded vessels
Pleuritic chest pain
Sharp pain on inspiration if pleura is involved
Dyspnea
Shortness of breath, especially in large abscess or bilateral disease
Crackles or bronchial breath sounds
On auscultation over affected area
Dullness to percussion
Due to underlying consolidation or fluid collection
โ 2. Systemic Signs
Sign
Description
Fever with chills and rigors
Common in acute infection
Night sweats
Due to ongoing infection
Fatigue, malaise
Generalized weakness due to chronic infection
Loss of appetite and weight loss
Especially in chronic or untreated cases
Clubbing of fingers
In chronic, longstanding cases due to hypoxia
๐จ Signs of Complications (if present):
Sudden worsening of dyspnea (rupture into pleura โ empyema)
Hypotension, confusion (suggesting sepsis)
Cyanosis (impaired gas exchange)
๐น DIAGNOSIS OF LUNG ABSCESS
Timely diagnosis is essential to prevent serious complications. It includes clinical evaluation, imaging, and laboratory tests.
Rule out tumor, foreign body, or bronchial obstruction
โ 6. Blood Investigations
Test
Purpose
CBC
Elevated WBC count (leukocytosis)
ESR/CRP
Elevated in active infection
Blood cultures
If sepsis is suspected
Liver and renal function tests
To monitor antibiotic effects and overall health status
โ 7. ABG / Pulse Oximetry
In moderate to severe cases to assess oxygenation status
๐น A. MEDICAL MANAGEMENT
The primary goals of medical treatment are to: โ Control infection โ Promote drainage of pus โ Prevent complications
โ 1. Antibiotic Therapy (Mainstay of Treatment)
๐ธ Empirical IV Antibiotics (Started before culture results):
Common Regimen
Coverage
Clindamycin OR Ampicillin-sulbactam
Good anaerobic and Gram-positive coverage
Ceftriaxone + Metronidazole
Broad-spectrum including anaerobes
Piperacillinโtazobactam
For severe, hospital-acquired, or polymicrobial infections
Vancomycin
Added if MRSA suspected
๐ฌ Modify antibiotic based on culture & sensitivity from sputum, bronchoscopy, or aspirate.
๐ธ Duration:
Typically 3โ6 weeks, depending on response and size of abscess
May start IV and later switch to oral antibiotics once improving
โ 2. Supportive Therapy
Supportive Care
Purpose
Antipyretics (e.g., paracetamol)
To reduce fever and improve comfort
Bronchodilators (if needed)
For bronchospasm or underlying COPD/asthma
Mucolytics and steam inhalation
Helps loosen and clear mucus
High-protein, high-calorie diet
Supports healing and immunity
Hydration (oral or IV)
Helps mobilize secretions and maintain fluid balance
โ 3. Airway Clearance Techniques
Postural drainage (positioning to allow gravity to aid sputum drainage)
Chest physiotherapy and incentive spirometry
Encouraging deep breathing and coughing
โ 4. Oxygen Therapy
If the patient is hypoxic or in respiratory distress
Use nasal cannula or face mask as needed
โ 5. Monitoring
Daily temperature charting, SpOโ monitoring
CBC, ESR, CRP for infection trend
Repeat chest X-ray or CT scan after 1โ2 weeks to monitor resolution
๐น B. SURGICAL MANAGEMENT
Surgery is reserved for cases where medical therapy fails, complications arise, or there is an underlying pathology.
โ 1. Percutaneous Aspiration or Drainage
Under CT or ultrasound guidance
For large abscess, poor antibiotic response, or abscess at risk of rupture
Inserted catheter allows pus to be drained externally
โ 2. Bronchoscopy
Not a surgical procedure, but important for:
Clearing obstructed bronchi
Removing foreign body
Collecting deep secretions for culture
Visualizing tumor or mass obstructing drainage
โ 3. Lobectomy / Segmentectomy
Surgical resection of the affected lobe or segment
Indicated when:
Persistent or recurrent abscess despite antibiotics
Massive hemoptysis
Abscess caused by underlying malignancy
Bronchopleural fistula or lung destruction
โ 4. Open Surgical Drainage
Rarely performed today but may be needed in emergency rupture, empyema, or when percutaneous drainage fails
โ 5. Management of Complications (e.g., Empyema, Sepsis)
Chest tube insertion if abscess ruptures into pleural space
ICU care if patient develops sepsis or ARDS
๐ด NURSING MANAGEMENT OF LUNG ABSCESS
๐น A. NURSING ASSESSMENT
โ Subjective Data:
Complaint of persistent productive cough
Reports of foul-smelling sputum, pleuritic chest pain
History of fever, fatigue, and recent pneumonia or aspiration
โ Objective Data:
Fever, tachypnea, tachycardia
Copious, purulent, foul-smelling sputum
Crackles, bronchial breath sounds, or dullness on percussion
Clubbing (in chronic cases)
Low SpOโ levels, possible signs of sepsis (confusion, hypotension)
๐น B. COMMON NURSING DIAGNOSES
Nursing Diagnosis
Related To
Evidenced By
Ineffective airway clearance
Accumulation of purulent secretions
Productive cough, abnormal lung sounds
Impaired gas exchange
Alveolar destruction, mucus plugging
Decreased SpOโ, cyanosis, tachypnea
Acute pain
Pleuritic inflammation
Reports of chest pain during deep breathing
Hyperthermia
Infection and inflammation
Elevated body temperature, chills
Activity intolerance
Hypoxia, fatigue
Shortness of breath on exertion
Risk for fluid volume deficit
Fever, sweating, poor intake
Dry mucous membranes, concentrated urine
Risk for sepsis
Systemic spread of infection
Elevated WBCs, hypotension, confusion (late sign)
๐น C. NURSING INTERVENTIONS AND RATIONALES
Nursing Intervention
Rationale
Monitor respiratory status and SpOโ regularly
Detect early signs of hypoxia or deterioration
Administer prescribed IV antibiotics
Essential to control the infection
Encourage effective coughing and deep breathing
Promotes airway clearance and prevents atelectasis
Assist with chest physiotherapy or postural drainage
Aids in mobilizing and draining thick secretions
Position in high-Fowlerโs or semi-Fowlerโs
Improves lung expansion and oxygenation
Provide oxygen therapy as needed
Maintains adequate oxygenation and reduces dyspnea
Monitor and record sputum characteristics (amount, color, odor)
Helps assess response to treatment and track changes
Administer analgesics/antipyretics as prescribed
Reduces fever, pain, and improves comfort
Encourage oral fluids (if not contraindicated)
Helps thin mucus and maintains hydration
Monitor temperature and WBC counts
To evaluate infection status and treatment effectiveness
Provide high-protein, high-calorie nutrition support
Promotes healing and supports immune function
Support rest with periods of activity as tolerated
Balances energy conservation with prevention of complications from immobility
๐น D. PATIENT AND FAMILY EDUCATION
Teach effective coughing techniques and incentive spirometry use
Stress importance of completing full course of antibiotics
Instruct on hydration and nutrition to aid recovery
Educate about early signs of complications:
Sudden increase in cough or hemoptysis
Chest pain worsening
Confusion or extreme weakness
Promote oral hygiene to reduce bacterial load (especially in aspiration-prone patients)
Discuss aspiration precautions in at-risk individuals (stroke, alcoholics, unconscious patients)
Encourage follow-up care and repeat imaging as per physicianโs advice
๐น E. EVALUATION CRITERIA
Patient maintains clear airway and effective gas exchange
Fever subsides, and infection parameters return to normal
Sputum production decreases and becomes less purulent
Pain is managed, and patient reports improved breathing
Patient demonstrates understanding of treatment, prevention, and self-care
โ ๏ธ COMPLICATIONS OF LUNG ABSCESS
If left untreated or inadequately managed, lung abscess can lead to severe and life-threatening complications.
๐น 1. Empyema
Spread of infection into the pleural space
Leads to pus accumulation, requiring chest tube drainage
๐น 2. Bronchopleural Fistula
Abnormal connection between bronchus and pleural cavity
Causes persistent air leak and empyema
๐น 3. Hemoptysis
Erosion of blood vessels near the abscess cavity
Can be mild to massive (life-threatening)
๐น 4. Sepsis / Septic Shock
Bacteria enter bloodstream โ systemic infection
Can result in multi-organ failure
๐น 5. Respiratory Failure
Due to severe lung damage, poor oxygen exchange
May require mechanical ventilation
๐น 6. Lung Fibrosis or Scarring
Long-term healing may lead to permanent loss of lung function
๐น 7. Spread to Other Organs
Especially in immunocompromised patients
Can cause brain abscess, endocarditis, or metastatic infections
๐น 8. Chronic Lung Abscess
Delayed or incomplete treatment can result in chronic abscess, requiring surgical intervention
โ KEY POINTS ON LUNG ABSCESS
โ๏ธ Definition: A localized area of necrosis in the lung parenchyma with pus-filled cavity formation, most commonly due to infection.
โ๏ธ Most Common Cause: Aspiration of oropharyngeal contents, especially in patients with altered consciousness, poor oral hygiene, alcoholism, stroke.
A respiratory cyst (or pulmonary cyst) is a fluid- or air-filled sac within the lung parenchyma that is lined by respiratory epithelium. These cysts can be congenital or acquired, and may be solitary or multiple, and asymptomatic or symptomatic depending on size and location.
๐ Cysts may be confused with bullae, blebs, or cavities โ but they are usually sharply demarcated, with a thin wall (<4 mm) and do not contain pus or solid tissue.
๐น CAUSES OF RESPIRATORY CYST
โ 1. Congenital Causes:
Congenital Pulmonary Airway Malformation (CPAM)
Bronchogenic cysts
Congenital lobar emphysema
Pulmonary sequestration
โ 2. Acquired Causes:
Cause
Description
Infections
Tuberculosis, Pneumocystis jirovecii, fungal infections (e.g., histoplasmosis) can cause cystic changes
Trauma
Lung laceration leading to post-traumatic air cyst
Symptoms vary from none (asymptomatic) to life-threatening in complicated cases.
Symptom
Description
Cough
May be dry or productive
Chest pain
Usually dull, may become sharp if ruptured
Shortness of breath (dyspnea)
Especially if large or multiple cysts
Recurrent infections
Due to cyst obstruction or mucus trapping
Hemoptysis
If nearby vessels are involved
Sudden chest pain + breathlessness
Suggests rupture โ pneumothorax
๐น DIAGNOSIS
โ 1. Chest X-ray
May show round, radiolucent lesion with defined margins
Air-fluid level if infected cyst
โ 2. High-Resolution CT (HRCT) Scan
Gold standard
Reveals size, wall thickness, communication with airways, and number/location of cysts
Helps distinguish from bullae or cavities
โ 3. MRI or Ultrasound (in mediastinal cysts)
For cysts near heart or diaphragm
โ 4. Bronchoscopy
For cysts near bronchi or when malignancy is suspected
โ 5. Pulmonary Function Test (PFT)
May show restrictive or obstructive changes
โ 6. Histopathology (Post-surgery)
Confirms type of cyst (bronchogenic, CPAM, etc.)
๐น MEDICAL MANAGEMENT
Observation: Small, asymptomatic cysts may not need intervention โ monitor with serial imaging
Antibiotics: If infection is suspected (e.g., fever, purulent sputum)
Bronchodilators: For associated airway obstruction
Oxygen therapy: In cases of hypoxia or breathlessness
Corticosteroids (rare): In inflammatory causes like Langerhans cell histiocytosis
๐น SURGICAL MANAGEMENT
Procedure
Indication
Video-Assisted Thoracoscopic Surgery (VATS)
Preferred for cyst excision or biopsy
Lobectomy or segmentectomy
For large, infected, or multiple cysts
Thoracotomy
If VATS is not feasible or in case of rupture/emergency
Cyst drainage (CT-guided)
In selected infected cysts
๐น NURSING MANAGEMENT
โ Assessment:
Monitor vital signs, breath sounds, SpOโ
Watch for signs of infection, pneumothorax, or respiratory distress
โ Interventions:
Position in semi-Fowler’s to ease breathing
Administer oxygen if required
Assist with chest physiotherapy and encourage deep breathing exercises
Administer antibiotics or bronchodilators as prescribed
Educate on early warning signs (e.g., sudden chest pain, fever)
Prepare and assist in diagnostic/surgical procedures
โ Patient Education:
Importance of follow-up imaging
Recognizing signs of rupture or infection
Post-operative breathing exercises and lung care
๐น COMPLICATIONS
Infection โ abscess or empyema
Cyst rupture โ pneumothorax
Hemoptysis
Compression of lung tissue โ hypoxia
Malignant transformation(rare in congenital cysts)
Bronchopleural fistula
โ KEY POINTS ON RESPIRATORY CYST
โ๏ธ A pulmonary cyst is a fluid or air-filled sac in the lungs, usually thin-walled and well-defined โ๏ธ Can be congenital (e.g., bronchogenic cyst) or acquired (due to infection, trauma, disease) โ๏ธ Many are asymptomatic, but large or infected cysts can cause respiratory symptoms or complications โ๏ธ HRCT is the best imaging tool to identify and characterize cysts โ๏ธ Treatment includes monitoring, antibiotics, or surgical removal in select cases โ๏ธ Nurses play a key role in respiratory monitoring, infection control, and post-op care โ๏ธ Major risks include rupture, infection, and lung damage
๐ค RESPIRATORY TUMORS (LUNG TUMORS)
๐น DEFINITION
Respiratory tumors refer to abnormal growths in the respiratory tract, most commonly in the lungs, bronchi, or trachea. These tumors may be:
Cell Mutation: Mutated cells bypass normal growth regulation and DNA repair mechanisms.
Uncontrolled Cell Growth: Forms a tumor mass that may:
Invade local tissue (bronchi, blood vessels, pleura)
Obstruct airways
Induce bleeding and inflammation
Angiogenesis and Metastasis:
Tumor creates its own blood supply
Spreads (metastasizes) to lymph nodes, brain, liver, bones
๐น TYPES OF RESPIRATORY (LUNG) TUMORS
โ 1. Non-Small Cell Lung Cancer (NSCLC) โ 85%
Adenocarcinoma โ most common, especially in non-smokers
Squamous cell carcinoma
Large cell carcinoma
โ 2. Small Cell Lung Cancer (SCLC) โ 15%
Aggressive, fast-growing
Early metastasis to brain, liver, bones
โ 3. Benign Tumors
Hamartomas, fibromas, papillomas
Usually asymptomatic, slow-growing
๐น SIGNS AND SYMPTOMS
Symptom
Description
Persistent cough
Often first symptom; may worsen over time
Hemoptysis
Blood in sputum due to tumor invasion
Chest pain
Dull or pleuritic; worsens with deep breathing
Shortness of breath (dyspnea)
Due to airway obstruction or pleural effusion
Hoarseness
If tumor compresses the recurrent laryngeal nerve
Weight loss, fatigue
Common systemic symptoms
Clubbing of fingers
In chronic hypoxia
Recurrent pneumonia or bronchitis
Tumor blocks airway โ infection
๐น DIAGNOSIS
Test
Purpose
Chest X-ray
First-line tool to detect mass
CT Scan (Thorax)
Detailed visualization of tumor size, location, and spread
Sputum cytology
Detects cancer cells in sputum
Bronchoscopy with biopsy
Direct visualization and tissue sample
Needle biopsy (CT-guided)
For peripheral lesions
PET Scan
Assesses metastasis and cancer activity
MRI/Brain CT
If brain metastasis is suspected
Pulmonary Function Test (PFT)
To assess lung capacity before surgery
๐น MEDICAL MANAGEMENT
Treatment
Description
Chemotherapy
Kills or shrinks cancer cells (mainstay for SCLC)
Radiotherapy
High-energy radiation to destroy tumor cells
Targeted therapy
EGFR inhibitors (e.g., gefitinib) for specific gene mutations
Immunotherapy
Boosts the immune system to attack cancer (e.g., nivolumab, pembrolizumab)
Palliative care
For symptom relief in advanced stages (pain, dyspnea, cough)
Smoking cessation support
Crucial to slow progression and improve therapy outcomes
๐น SURGICAL MANAGEMENT
Procedure
Indication
Lobectomy
Removal of one lung lobe (most common curative surgery)
Pneumonectomy
Removal of entire lung (for centrally located tumors)
Segmentectomy / Wedge resection
For small, early-stage tumors
Thoracotomy / VATS
Open or minimally invasive access to lungs
Mediastinal lymph node dissection
To check spread and staging
๐น NURSING MANAGEMENT
โ Pre-Operative Care:
Educate patient on procedure and breathing exercises
Ensure smoking cessation if not already
Monitor SpOโ, RR, lung sounds
Prepare for diagnostic tests (biopsy, CT, bronchoscopy)
โ Post-Operative / Treatment Care:
Monitor for respiratory distress, infection, or bleeding
Assist with deep breathing, coughing, incentive spirometry
Maintain chest drainage systems (if lobectomy/pneumonectomy)
Administer oxygen therapy as prescribed
Manage pain and anxiety
Provide nutritional support
Educate on chemotherapy side effects: nausea, fatigue, neutropenia
Psychological support and encourage support group participation
๐น COMPLICATIONS
Airway obstruction
Pleural effusion or empyema
Massive hemoptysis
Respiratory failure
Metastasis to brain, liver, bones
Superior vena cava syndrome
Post-op pneumonia or lung collapse
Psychological issues (anxiety, depression)
โ KEY POINTS ON RESPIRATORY TUMORS
โ๏ธ Most respiratory tumors are malignant and usually originate in lung tissue โ๏ธ Smoking is the most important risk factor โ๏ธ Persistent cough, hemoptysis, weight loss, and dyspnea are red flags โ๏ธ CT scan, bronchoscopy, and biopsy confirm diagnosis โ๏ธ Treatment may include surgery, chemotherapy, radiation, and targeted therapy โ๏ธ Nursing care focuses on respiratory monitoring, post-op care, emotional support, and education โ๏ธ Prognosis depends on stage at diagnosis, type (NSCLC vs SCLC), and treatment response
๐ฅ CHEST INJURIES
๐น DEFINITION
Chest injury refers to any trauma to the chest wall, lungs, heart, great vessels, trachea, or diaphragm due to blunt or penetrating force.
Can range from mild (bruises, rib fractures) to life-threatening (pneumothorax, flail chest, cardiac tamponade).
๐น CAUSES OF CHEST INJURY
Cause
Examples
Blunt trauma (most common)
Road traffic accidents, falls, sports injuries
Penetrating trauma
Gunshot wounds, stab injuries
Blast injuries
Explosion-related (military/industrial settings)
Surgical or iatrogenic
Post chest surgery, central line placement
๐น TYPES OF CHEST INJURIES
โ 1. Blunt Chest Injuries
Rib fractures
Flail chest
Pulmonary contusion
Hemothorax
Pneumothorax
Cardiac contusion
โ 2. Penetrating Chest Injuries
Open pneumothorax (sucking chest wound)
Hemothorax
Injury to heart or great vessels
Diaphragmatic rupture
โ 3. Combined Injuries
Tension pneumothorax
Tracheobronchial injury
Esophageal rupture
Cardiac tamponade
๐น PATHOPHYSIOLOGY
Blunt or penetrating trauma damages chest wall or internal thoracic structures.
Results in:
Impaired ventilation and gas exchange
Air or blood accumulation in pleural space (pneumothorax/hemothorax)
Elevate head of bed to 30โ45ยฐ to ease breathing
Encourage deep breathing, coughing, and incentive spirometry
Provide pain relief: analgesics, positioning
Prepare for emergency interventions (e.g., thoracostomy tray)
Maintain strict asepsis for open wounds or drains
โ Education:
Teach patient splinting of chest during coughing
Educate on signs of complications (e.g., increasing breathlessness, bleeding)
In post-op cases: teach chest physiotherapy and mobility
๐น COMPLICATIONS
Tension pneumothorax
Hemothorax
Lung collapse (atelectasis)
Infection โ pneumonia or empyema
Respiratory failure
Cardiac tamponade
Sepsis
Chronic pain or rib deformity
โ KEY POINTS ON CHEST INJURIES
โ๏ธ Chest injuries may be blunt or penetrating, and can be life-threatening โ๏ธ Common signs: dyspnea, chest pain, reduced breath sounds, tracheal deviation โ๏ธ Chest X-ray and CT are essential for diagnosis โ๏ธ Management includes oxygen, chest tube, pain control, and surgery if needed โ๏ธ Nurses must monitor for hypoxia, bleeding, shock, and provide respiratory support โ๏ธ Early recognition and intervention are critical for survival โ๏ธ Flail chest, tension pneumothorax, and cardiac tamponade are emergencies
๐ฆ ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)
๐น DEFINITION
Acute Respiratory Distress Syndrome (ARDS) is a life-threatening condition characterized by acute inflammation and diffuse alveolar-capillary damage leading to:
Increased pulmonary capillary permeability
Non-cardiogenic pulmonary edema
Severe hypoxemia (low blood oxygen)
Decreased lung compliance and respiratory failure
๐ ARDS typically occurs within 1 week of a known clinical insult (e.g., sepsis, trauma, pneumonia) and is not due to heart failure or fluid overload.
๐น CAUSES OF ARDS
ARDS can be caused by direct or indirect lung injury.
โ 1. Direct Lung Injury (Primary Pulmonary Causes)
Lung compliance remains low, gas exchange still impaired
โ 3. Fibrotic Phase (After 2โ3 weeks)
Irreversible lung fibrosis and scarring
Persistent hypoxia, reduced lung compliance
May lead to chronic respiratory failure or death
๐ Key Outcomes of ARDS Pathophysiology:
Alveolar flooding
Reduced gas exchange
Hypoxemia
Decreased lung compliance
Increased work of breathing
Pulmonary hypertension (in severe cases)
๐น SIGN AND SYMPTOMS
Symptoms typically develop within 12 to 48 hours after the initial injury or illness (e.g., sepsis, aspiration, trauma). The hallmark symptom is severe hypoxia that does not improve with oxygen therapy.
โ Early Symptoms (Mild ARDS)
Symptom
Description
Dyspnea
Sudden onset of difficulty breathing
Tachypnea
Rapid shallow breathing
Hypoxemia
Low oxygen saturation, even with oxygen support
Cough
Usually dry or with frothy sputum
Restlessness, anxiety
Due to low oxygen levels
Use of accessory muscles
Increased work of breathing
Tachycardia
Increased heart rate as a response to hypoxia
โ Progressive / Late Symptoms (Severe ARDS)
Symptom
Description
Cyanosis
Bluish discoloration of lips, nail beds (late sign)
Altered mental status
Confusion, lethargy, or agitation due to brain hypoxia
Fatigue and respiratory muscle exhaustion
Can lead to respiratory failure
Crackles or rales on auscultation
Due to fluid in alveoli
Hypotension
May occur in sepsis-related ARDS or as respiratory failure progresses
Decreased urine output
Due to poor perfusion/kidney involvement in multi-organ failure
๐น DIAGNOSIS OF ARDS
ARDS is diagnosed based on clinical features, imaging, oxygenation levels, and ruling out cardiac causes of pulmonary edema.
โ 1. Berlin Criteria for ARDS Diagnosis (2012)
To diagnose ARDS, all of the following must be met:
Criteria
Details
Timing
Symptoms occur within 1 week of known clinical insult or new/worsening respiratory symptoms
Chest imaging
Bilateral opacities on chest X-ray or CT (not fully explained by effusion, lobar collapse, or nodules)
Origin of edema
Respiratory failure not explained by cardiac failure or fluid overload (rule out CHF with echocardiogram)
Oxygenation (PaOโ/FiOโ ratio)
<300 mmHg with PEEP โฅ5 cm HโO indicates severity
โ 2. Chest X-ray / CT Scan
Imaging Modality
Findings
Chest X-ray
Bilateral โwhite-outโ infiltrates (diffuse opacities), no cardiomegaly
CT chest
More sensitive โ shows diffuse ground-glass opacities, alveolar edema
โ 3. Arterial Blood Gas (ABG)
Parameter
Finding
PaOโ
โ (hypoxemia)
PaCOโ
Initially โ (due to hyperventilation), then โ in late stages
pH
Respiratory alkalosis โ acidosis as condition worsens
๐ PaOโ/FiOโ ratio is used to assess severity:
Mild ARDS: 200โ300 mmHg
Moderate: 100โ200 mmHg
Severe: <100 mmHg
โ 4. Echocardiography
To rule out cardiac causes (e.g., left ventricular failure) as a source of pulmonary edema
โ 5. Laboratory Tests
CBC: โ WBCs if infection/sepsis
CRP, Procalcitonin: Inflammatory markers
Cultures: Blood, sputum, urine to identify infection source
Serum lactate: May be โ in sepsis-related ARDS
๐น A. MEDICAL MANAGEMENT
The primary goals of ARDS management are to:
โ Improve oxygenation โ Treat the underlying cause โ Prevent complications (e.g., infection, multi-organ failure)
๐ ARDS is a medical emergency and is typically managed in an ICU setting with mechanical ventilation support.
โ 1. OXYGEN THERAPY
Method
Use
Nasal cannula or face mask
For mild hypoxemia in early stages
High-flow nasal oxygen (HFNO)
Provides heated, humidified oxygen
Non-invasive ventilation (NIV)
For mild-to-moderate ARDS in selected cases
Mechanical ventilation (intubation)
For moderate to severe ARDS or if NIV fails
๐ก Low tidal volume ventilation (LTVV) is standard:
4โ8 mL/kg body weight to prevent lung injury
PEEP (positive end-expiratory pressure) used to keep alveoli open
โ 2. PRONE POSITIONING
Placing patient face-down (prone) improves ventilation-perfusion mismatch and oxygenation
Recommended in moderate to severe ARDS (PaOโ/FiOโ <150 mmHg)
โ 3. TREAT THE UNDERLYING CAUSE
Cause
Treatment
Sepsis
IV fluids, vasopressors, broad-spectrum antibiotics
Pneumonia
Targeted antibiotic/antiviral therapy
Aspiration
Airway suctioning, antibiotics if infected
Pancreatitis or trauma
Supportive and specific organ-based care
โ 4. FLUID MANAGEMENT
Conservative fluid strategy after initial resuscitation
Prevents worsening pulmonary edema
โ 5. PHARMACOLOGICAL SUPPORT
Drug Type
Role
Antibiotics
If bacterial infection or sepsis
Sedatives/analgesics
For ventilated patients (e.g., midazolam, fentanyl)
Neuromuscular blockers
In severe ARDS to improve oxygenation and synchronize breathing
Corticosteroids (e.g., dexamethasone)
May be used in selected cases to reduce inflammation (controversial but used in COVID-19 ARDS)
โ 6. NUTRITIONAL SUPPORT
Start enteral feeding within 48 hours (if possible) to maintain gut integrity and immunity
โ 7. MONITORING
Continuous monitoring of:
SpOโ, ABG, vitals
Urine output for kidney function
Ventilator settings and alarms
๐น B. SURGICAL / ADVANCED INTERVENTIONS
ARDS is primarily managed medically, but advanced life-support techniques may be considered in severe or refractory cases.
โ 1. Extracorporeal Membrane Oxygenation (ECMO)
Description
Indications
ECMO is a life-support system that oxygenates blood outside the body and returns it
Mortality 30โ50%, higher in elderly or multi-organ failure
๐ฅ PULMONARY EMBOLISM (PE)
๐น DEFINITION
Pulmonary Embolism is a sudden blockage of a pulmonary artery or one of its branches by a blood clot (thrombus) or other material (fat, air, amniotic fluid) that travels to the lungs from another part of the body, usually the deep veins of the legs (DVT).
๐ It is a life-threatening emergency that can lead to hypoxia, pulmonary hypertension, right heart failure, or sudden death.
๐น CAUSES / RISK FACTORS
Most pulmonary embolisms arise from deep vein thrombosis (DVT) โ part of venous thromboembolism (VTE).
โ 1. Thrombotic Embolism (Most Common)
Blood clots from deep veins of the legs or pelvis travel to the lungs
โ 2. Other Embolic Sources
Type
Examples
Fat embolism
Long bone fractures, orthopedic surgery
Air embolism
IV air entry, trauma, surgery
Amniotic fluid embolism
During labor or postpartum
Tumor emboli
From cancerous tissue in circulation
Septic emboli
From infected heart valves or central lines (e.g., endocarditis)
โ Major Risk Factors (Virchowโs Triad)
Category
Examples
Venous stasis
Prolonged bed rest, surgery, immobility, obesity
Endothelial injury
Trauma, surgery, IV lines, smoking
Hypercoagulability
Cancer, pregnancy, oral contraceptives, clotting disorders (e.g., Factor V Leiden)
๐น PATHOPHYSIOLOGY OF PULMONARY EMBOLISM
Formation of a thrombus (typically in deep leg veins โ DVT)
Embolization: The clot detaches and travels through venous circulation โ right atrium โ right ventricle โ pulmonary artery
Lodgment in pulmonary circulation
Obstruction of blood flow to part of the lung
Affects ventilation-perfusion (V/Q) balance
Impaired gas exchange
Alveoli are ventilated but not perfused โ dead space ventilation
Leads to hypoxemia, hypocapnia, dyspnea
Increased pulmonary vascular resistance
Leads to pulmonary hypertension
Causes right ventricular strain or failure
Systemic hypotension and shock
In massive PE, cardiac output drops โ circulatory collapse or sudden death
โ ๏ธ Massive PE can cause sudden cardiac arrest, while smaller emboli may cause gradual symptoms or silent hypoxia.
๐ง Key Consequences:
Gas exchange failure
Right heart strain or failure
Sudden cardiovascular collapse
Inflammatory response and surfactant dysfunction
โ ๏ธ Signs and Symptoms of Pulmonary Embolism
Symptoms can vary depending on the size and location of the clot and the patientโs overall health. They often develop suddenly.
๐ข Common Symptoms:
Symptom
Description
Sudden shortness of breath
Most common symptom; not related to exertion
Chest pain
Sharp, stabbing pain that may worsen with deep breathing (pleuritic pain)
Cough
Sometimes with blood-streaked sputum (hemoptysis)
Tachycardia
Rapid heart rate as the heart compensates for impaired circulation
Tachypnea
Rapid breathing due to hypoxia
Cyanosis
Bluish discoloration of skin/lips due to low oxygen
Light-headedness or syncope
Fainting due to reduced cardiac output
Leg swelling/pain
Especially in one legโmay indicate DVT (source of embolism)
Anxiety or feeling of doom
Often reported by patients during acute PE
๐งช Diagnosis of Pulmonary Embolism
Diagnosis is based on clinical suspicion, risk factors, symptoms, and confirmatory tests.
1. ๐ฉบ Clinical Assessment:
History: Recent surgery, immobility, history of DVT/PE, cancer, pregnancy
Physical Exam: Respiratory distress, signs of DVT
2. ๐งฎ Scoring Tools:
Wells Score โ Assesses probability of PE
Geneva Score
3. ๐ฉป Diagnostic Tests:
Test
Purpose/Use
D-dimer Test
Elevated in presence of clots; useful in low-risk patients
CT Pulmonary Angiography (CTPA)
Gold standard โ Visualizes clots in pulmonary arteries
Ventilation-Perfusion (V/Q) Scan
Useful if CTPA is contraindicated (e.g., kidney disease, pregnancy)
Chest X-ray
May be normal or show signs like pleural effusion or atelectasis
ECG
May show sinus tachycardia or classic S1Q3T3 pattern
Inserted into IVC to catch clots from the lower limbs before reaching lungs
Used when anticoagulation is contraindicated or in recurrent PE despite treatment
May be temporary or permanent
๐ Summary Table:
Management
Key Points
Medical
Oxygen, anticoagulants (heparin, DOACs), thrombolytics (tPA), supportive care
Surgical
Open or catheter-directed embolectomy, IVC filter in selected patients
๐งโโ๏ธ NURSING MANAGEMENT OF PULMONARY EMBOLISM
Pulmonary Embolism is a medical emergency, and nurses play a critical role in the early detection, immediate management, continuous monitoring, and post-treatment care of affected patients.
High-risk groups: Post-surgical patients, prolonged immobilization, pregnant women, cancer patients, smokers, those with clotting disorders.
Timely intervention can save lives and prevent long-term complications.
๐ซ Health Behaviours to Prevent Respiratory Illness
Respiratory illnesses include common cold, flu, pneumonia, bronchitis, asthma, tuberculosis, COVID-19, and chronic diseases like COPD. These can spread through air, droplets, or develop due to environmental or lifestyle factors. Prevention focuses on strengthening immunity, avoiding infection, and protecting lung health.
โ 1. Personal Hygiene Practices
Behaviour
Why Itโs Important
Regular handwashing with soap and water
Reduces spread of viruses and bacteria
Use of hand sanitizer (at least 60% alcohol) when soap is unavailable
Kills pathogens on hands
Covering mouth/nose while sneezing or coughing (use tissue/elbow)
Prevents droplet transmission
Avoid touching face (eyes, nose, mouth) with unwashed hands
Limits entry of germs into body
โ 2. Immunization and Preventive Vaccines
Vaccine
Protection Against
Influenza vaccine (annually)
Seasonal flu
Pneumococcal vaccine
Pneumonia and meningitis (esp. for elderly and at-risk people)
COVID-19 vaccine
SARS-CoV-2 virus
BCG vaccine (in infants)
Tuberculosis
Tdap (Tetanus, Diphtheria, Pertussis)
Whooping cough (pertussis) and others
๐ Staying up to date with vaccines boosts herd immunity and prevents outbreaks.
โ 3. Healthy Lifestyle Habits
Behaviour
Respiratory Benefit
Balanced diet rich in fruits, vegetables, and antioxidants
Supports immune system
Regular physical activity (30 mins/day)
Improves lung capacity and circulation
Adequate hydration
Keeps mucous membranes moist and functional
Adequate sleep (7โ9 hrs/night)
Strengthens immune defense
Stress reduction (yoga, meditation)
Chronic stress weakens immunity
โ 4. Avoidance of Risk Factors
Avoid
Why?
Smoking (active and passive)
Major cause of COPD, lung cancer, infections
Indoor air pollution (cooking smoke, incense, mold)
Causes chronic bronchitis, asthma attacks
Outdoor air pollution (industrial smoke, traffic)
Triggers asthma, worsens lung function
Exposure to allergens or chemicals
Can cause or worsen respiratory illness
Overcrowded, poorly ventilated spaces
Promotes spread of airborne diseases like TB and flu
โ 5. Environmental Control
Behaviour
Outcome
Improve home ventilation
Reduces indoor pollutants, disperses germs
Use of air purifiers or exhaust fans
Helpful in urban or polluted areas
Avoid burning biomass fuels indoors
Reduces smoke-related respiratory issues
Proper disposal of waste
Prevents breeding of pathogens and vectors
Avoiding use of strong aerosols/chemicals
Prevents irritation and asthma attacks
โ 6. Respiratory Etiquette and Protection
Practice
Purpose
Use of masks (especially in crowded or polluted areas)
Reduces inhalation of pollutants and spread of infectious droplets
Isolation during infection (home rest if sick)
Prevents community spread
Use of personal items (towels, utensils) separately when infected
Prevents fomite transmission
โ 7. Early Detection and Regular Health Checkups
Seek medical help for symptoms like persistent cough, breathlessness, or fever
Routine checkups for high-risk groups (elderly, smokers, asthmatics, COPD patients)
Pulmonary function tests (PFTs) โ helpful in chronic illness monitoring
โ 8. Community and Workplace Health Measures
Workplace ventilation standards
Health education campaigns on hygiene and vaccination
Smoke-free zones and anti-smoking laws
Respiratory health screening in high-risk populations