Respiratory Study Guide for the CCRN

Airway Concerns

Patients may have numerous complications with their airway leading to acute care hospitalization. The following section will focus on some of the most common airway concerns noted throughout the CCRN® exam.

Aspiration

Aspiration is the event in which solid or liquid material is inhaled into the lungs. Common substances that are aspirated include gastric contents, oropharyngeal bacteria, and foreign objects. Aspiration events may lead to respiratory obstruction, pneumonitis, or pneumonia.

Aspiration of gastric content causes severe chemical pneumonitis. The acidity of the gastric content can worsen the trauma to the lungs and subsequent pulmonary response. Irritation to the trachea, bronchioles, and alveoli with acidic content may lead to bronchospasms, atelectasis, interstitial edema, and hemorrhage. Aspirated material can then cause pneumonia by introducing bacteria into the airways. In the acute care setting, intrapulmonary shunting, V/Q mismatch, and an increase in pulmonary artery pressure will be noted. While non-acidic contents are less damaging, they still require monitoring based on the severity and volume of contents aspirated. Some aspiration events have irritation that resolves in a few days, while other events may lead to progressive respiratory failure and death if not treated appropriately.

Foreign object aspiration can cause obstruction to varying areas of the lungs. Obstruction can lead to dyspnea or asphyxiation. Initial symptoms include severe coughing, gagging, wheezing, or sternal retractions. Instead of expelling the object, the object can instead travel deeper into the lungs, particularly the right bronchus in adults.

Larynx obstruction significantly diminishes a person’s ability to breathe and may lead to respiratory arrest if not quickly corrected. A classic sign of a larynx obstruction is stridor, a high-pitched sound during breathing. Some patients may have asymptomatic aspiration or have symptoms that quickly resolve despite the continued presence of the aspirated material. A delayed response may then occur as the material becomes infected, causing further inflammation and irritation to the pulmonary tissues.

DIagnosis

Diagnosis of aspiration includes clinical findings of hypoxemia, as evidenced by an arterial blood gas reading, presence of lung infiltrates on chest X-ray, and increased white blood cell count in light of an infectious cause. Just as with non-aspiration pneumonias, aspiration pneumonia presents with symptoms such as cough, increased sputum expulsion, respiratory distress, cyanosis, tachycardia, and hypotension.

Treatment

Treatment of aspiration primarily focuses on securing a stable, open airway and providing adequate oxygenation. Foreign bodies must be removed promptly, usually with laryngoscopy or rigid bronchoscopy. Supplemental oxygen and symptomatic respiratory support are used to help provide the patient comfort and adequate ventilation. Antibiotics may be used if symptoms persist greater than 48 hours or if infection is suspected.

Prevention

Nurses are responsible for monitoring those who are at increased risk for aspiration. Foreign object aspiration is highest during early childhood and the elderly period. Persons with decreased level of consciousness, depressed gag or swallowing reflex, gastric distention, and gastroesophageal reflux disorders (GERD) are at high risk for aspiration. Patients who are intubated must be monitored closely as their airway is stinted open to provide appropriate ventilation. If the patient has an increase in oral secretions or vomits, the endotracheal tube provides direct, relatively unprotected, access to the lungs. Enteral feeding by way of feeding tube may also put the patient at risk for gastric overdistention or displacement of the feeding tube into the esophagus, leading to overflow of gastric or enteral feeding contents. Unless otherwise contraindicated, patients at a high aspiration risk should always sit upright especially while eating, drinking, or if tube feedings are running.

Asphyxia

Asphyxia occurs when the body is deprived of oxygen for an extended period of time, resulting in unconsciousness or even death. It can occur from different conditions, including near-drowning and mechanical causes such as traumatic injuries and choking. These are extremely fatal and can lead to multi-organ dysfunction. In asphyxiation, we are especially concerned with the brain as cells begin dying within five minutes of being deprived of oxygen which can lead to severe brain injuries such as hypoxic encephalopathy, disabilities, cognitive delays, and seizures.

Near-Drowning Asphyxia

In near-drowning asphyxia, also known as submersion asphyxiation, the central nervous system, pulmonary structures, and other organs may become significantly and irreversibly damaged both due to the lack of oxygen and presence of aspirated fluids.

Symptoms and Diagnosis

Many times the body will respond to a drowning event by becoming hypothermic. Water conducts heat away faster than air plus the body helps protect the vital organs by shunting blood toward the brain and heart and away from the other tissues of the body.

Treatment

Treatment for near-drowning asphyxia includes establishing an airway to ensure breathing and circulation are appropriate for the patient . Pulmonary care should involve at least 72 hours of respiratory monitoring to evaluate for pulmonary deterioration. Oxygen support should be provided as needed to keep \(\text{SpO}_2\) greater than 94%. If the patient must be intubated, minimizing excessive use of positive-end expiratory pressure (PEEP) is recommended to avoid barotrauma and changes to cardiac output.

Patients must also have frequent neurologic assessments to identify changes in consciousness or other signs of increased intracranial pressure (e.g., headache, nausea, vomiting, asymmetric or dilated pupils). A nasogastric (NG) tube may be placed to provide gastric decompression and reduce the risk of aspiration. Patients, if they are hypothermic due to the near-drowning event, should be rewarmed slowly. Warming should not occur faster than \(0.5\) to 1 degree centigrade per hour to prevent rewarming shock, which can cause cardiovascular collapse.

Mechanical Asphyxia

Mechanical asphyxia is caused by external forces that physically prevent ventilation. It may occur due to a variety of injuries including hanging, strangulation, choking (e.g., by foreign object), chest compression, thoracic crush injuries, and other traumas. In crush injuries, the lungs are generally not the only organ damaged in the event. The patient may also have injury to the heart, liver, spleen, abdomen, and other organs depending on the location and duration of the crushing event. In addition, a heavy object compressing the chest or poor positioning in very small spaces can lead to this kind of asphyxia as well.

Mechanical asphyxia may also occur from strangulation or choking. Nurses should understand common findings of each type of strangulation injury: manual, ligature, and hanging. In manual strangulation, the patient may present with crush injuries of the throat with or without bruising, discoloration (cyanosis) of the face not matched with the rest of the body, and facial petechiae. Ligature strangulation is similar to manual strangulation, though the throat markings differ. Instead of crushing, there is an indented area surrounding the neck in ligature strangulation. Neck markings in hanging appear as a v-shaped marking on the throat that does not completely surround the neck.

Treatment

Priority nursing interventions for traumatic asphyxia include establishing the ABCs of airway, breathing, and circulation. Some patients may need to be prepped for surgery, especially if their asphyxia is caused by persistent airway obstruction. While bronchoscopy may be helpful in the event of choking on a foreign body, some patients may need placement of a temporary (or permanent) airway via tracheostomy to restore airflow to the pulmonary system.

Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease is a general classification for progressive lung diseases. Individuals may have chronic bronchitis, emphysema, or both of these conditions simultaneously. COPD is an irreversible, progressive condition. It can be classified in stages 1 (mild) to 4 (very severe). These disease processes will be reviewed in the sections below.

Bronchitis

In order to be diagnosed with chronic bronchitis, patients must have a chronic, severe, productive cough for greater than three months per year for at least two years in a row. Dyspnea and frequent respiratory infections may complicate the chronic cough, worsening the condition both acutely and over time. The inflammatory response associated with bronchitis causes vasodilation, congestion, mucosal edema, and bronchospasm. The airways are the primary target, rather than the alveoli.

Patients at increased risk for chronic bronchitis include those who smoke, those who have increased exposure to secondhand smoke, those living in highly polluted areas, those who are over 45 years old, and those who have careers in fields with increased chance of foreign airborne particle inhalation (construction, chemical production, etc.). Women tend to develop chronic bronchitis twice as often as men.

Emphysema

Emphysema is also primarily caused by smoking but can also be caused by chemical occupational exposures (coal, firefighter, construction, asbestos) or Alpha-1 antitrypsin disease, which is a rare genetic disorder. The emphysema cascade begins with irritation and inflammation of the bronchioles, which increases mucus production that obstructs the airway, causing tissue injury, decreased surfactant, and bronchiolar collapse. Obstruction of the airway can also cause distention and air trapping in the alveoli, which leads to enlargement and stretching of the air sacs, decreasing their ability to recoil. The alveoli then fuse together, decreasing the surface area available for gas exchange.

Symptoms

Patients with bronchitis tend to appear with edema, cyanosis, and fatigue as well as the productive cough. The phrase “blue bloater” is sometimes used to describe chronic bronchitis as these patients have more swelling and cyanosis than emphysema.

Clinically in emphysema, nurses may expect patients to have dyspnea on exertion and at rest. The patients may experience productive and nonproductive coughing, tachypnea, pursed-lip breathing, malnutrition, muscle wasting, decreased ventilation (breath sounds), and structural changes to their rib cage (“barrel chest”). Think of the phrase “pink puffer” used to describe emphysema as these patients maintain relatively normal oxygen levels so their skin color is more pink and they have a puffing breathing pattern with the pursed lips.

As the disease advances, the cardiac system will also become involved as the right ventricular afterload is increased, causing right-sided heart failure (cor pulmonale), hypertrophy of the chambers, and decreased left ventricle filling and cardiac output. Additionally, acid-base imbalances such as respiratory acidosis can occur as well.

Diagnosis

The gold standard diagnostic tool is spirometry to confirm diagnosis and establish staging. Diagnosis is made based on the following ratio: forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) of less than 0.70.

Treatment

While COPD may not be reversible, it can be managed to reduce pulmonary damage and progressive lung changes. Nurses must provide patient education to help manage this condition. Patients should be instructed on the importance of smoking cessation and being compliant with their prescribed medications.

An important part of long-term treatment for COPD includes prevention of acute exacerbations by avoiding any irritants and preventing illness. Bronchodilators (albuterol and salmeterol), inhaled corticosteroids (Pulmicort®, Vanceril®), and oral corticosteroids (prednisone) can be used, as well as possible long-term use of supplemental oxygen therapy, and pulmonary rehabilitation. Acute exacerbations may be further treated with antibiotics (if infection is suspected) and intravenous corticosteroids to reduce inflammation. Surgery may be indicated to remove bullae, reduce lung volume, and, in rare cases, perform a lung transplant.

Chronic Asthma

Asthma is classified by inflammation of the bronchi of the lungs. This is then complicated by the narrowing of pulmonary structures, increased mucus production, and air trapping. The most common symptoms of asthma are cough, wheeze, and dyspnea. Asthma is a chronic condition and if left untreated can cause airway remodeling, fibrotic changes, and **permanent obstruction.

Symptoms

Chronic asthma may have recurring symptoms of nighttime cough, chest tightness, exertional dyspnea, and daytime cough. While asthma is a chronic condition, acute exacerbations may occur, worsening the airway obstruction. Exacerbations may be triggered by allergies, respiratory viruses, idiosyncratic reactions to NSAID or beta-blocker medication, esophageal reflux, stress, or environmental irritants.

Treatment

Treatment of asthma includes reducing identified triggers, quick treatment of infections, bronchodilators, long-acting beta-2 agonists, and inhaled glucocorticoids. Bronchodilator inhalers are typically classified into two categories: short-acting (rescue) and long-acting (maintenance). Short-acting or rescue inhalers are used to treat acute exacerbations while long-acting or maintenance inhalers are taken daily to prevent exacerbations. In some cases, heliox administration may be required to improve oxygen exchange. Sedatives and muscle relaxation may also be used if the patient is unable to achieve control of symptoms.

Status Asthmaticus

Status asthmaticus may occur in those with chronic asthma. It is a severe response of bronchospasm, inflammation, pulmonary obstruction, and decreased ventilation that does not respond to typical asthma therapies. It is usually triggered by a known aggravator such as an allergen, environmental pollution, stress, or exertion. The inflammation worsens due to cytokine production from mast cells and T lymphocytes. This increases the blood flow into the lungs, causing fluid accumulation and destruction of the pulmonary lining. This condition is a medical emergency that can lead to respiratory failure and death if not treated promptly.

Symptoms

Patients in status asthmaticus will present to an acute care facility with these common symptoms: audible wheezing, airway obstruction, sternal retractions, intercostal retractions, tachypnea, decreasing oxygen saturations, and forced expiration (tripod positioning). Due to the stress on the lungs, the cardiac system begins to suffer due to increased left ventricular afterload and increased pulmonary edema. If the patient is hypoxic, there may additionally be increased pulmonary vascular resistance and increased right ventricular afterload. Cardiac and respiratory decompensation will occur if not treated quickly.

The patient should be monitored for pulsus paradoxus. Nurses assessing for this condition will notice the patient having a decreased pulse on inspiration and an increased pulse on expiration. When auscultating heart sounds, extra beats with inspiration may be heard. If found, pulsus paradoxus is an indicator for worsening severity of asthma and indicative of impaired cardiopulmonary function. Arterial blood gas reading on a patient with status asthmaticus will likely show metabolic and/or respiratory acidosis. Metabolic acidosis occurs due to poor oxygen delivery causing tissue hypoxia and to compensate your body switches to anaerobic metabolism and produces lactic acid as a byproduct. Respiratory acidosis occurs due to the airway blockage which prevents the blow off of carbon dioxide causing build up.

Treatment

Treatment for status asthmaticus include the use of beta agonists (albuterol), corticosteroids, and theophylline. Theophylline is not part of first-line asthma treatment due to its narrow therapeutic index, meaning the difference between an effective dose and toxic one is small. Review common medications in these classifications, their indication, and any side effects or contraindications.

Supplemental oxygen needs to be applied. Patients may need to be intubated and mechanically ventilated as a last resort option. Intubating these patients is very challenging and can lead to further complications. Inflammation can be so severe that passing an endotracheal tube is not possible. In these cases the physician may need to perform a tracheostomy. This is when a hole is created in the neck to create a new airway. Patients with severe status asthmaticus are rarely unable to meet their base perfusion needs and may need to be placed on ECMO (extracorporeal membrane oxygenation) until the lungs have time to recover from the inflammation and damage.