CORONAVIRUS DISEASE 2019 (COVID-19)

Novel Coronavirus (2019-nCoV) causing an outbreak of respiratory illness in the city of Wuhan, Hubei province, China. Despite Wuhan and other Chinese cities, the COVID-19 has spread to almost more than 70 locations internationally and more than 1.35 lakh were found positive and more than 3500 were die globally.

In INDIA, COVID-19 cases have been confirmed in Kerala, Delhi, U.P., Rajasthan, Tamil Nadu and Jammu & Kashmir State. Total 39 cases were confirmed till date out of that 3 were recovered from the state of Kerala and still no any deaths have been reported.

Coronavirus

Coronaviruses are a family of viruses that can cause illnesses such as the common cold.

This family having six broad classifications

1. Human coronavirus 229 E (HCoV-229E)
2. Human coronavirus NL63 (HCoV-NL63)
3. Human coronavirus O43 (HCoV-OC43)
4. Human coronavirus HKU1 (HCoV-HKU1)
5. Middle East Respiratory syndrome MERS coronavirus (MERS -CoV)
6. Severe acute respiratory syndrome SARS coronavirus (SARS-CoV)
7. Novel Coronavirus (2019-nCoV) now seventh new coronavirus reported on 2019.

Transmission

• It's unclear exactly how contagious the new coronavirus is.
• Commonly, it is found in the animals.
• Rarely, it can be transmitted from animals to humans.
• Once’s it transferred to human then it will spread person to person.
• It appears to be spreading from person to person among those in close contact.
• It may be spread by respiratory droplets released when someone with the virus coughs or sneezes.

Clinical Presentation

• Signs and symptoms of COVID-19 may appear 2 to 14 days after exposure.
• This is very similar with other respiratory illnesses, such as influenza and common cold.
• It includes-
• 90% case fever
• 80% case fatigue and dry cough
• 20% shortness of breath or difficulty breathing
• 15% respiratory distress
• The severity of COVID-19 symptoms can range from very mild to severe.
• People who are older age, and underlying chronic medical conditions such as lung disease, cancer, heart failure, cerebrovascular disease, renal disease, liver disease, diabetes, immunocompromising conditions, and pregnancy, may be at higher risk of serious illness.
• Risk factors for COVID-19 appear to include:
• Recent travel from or residence in an area with ongoing spread of COVID-19 as determined by CDC or WHO
• Close contact with someone who has COVID-19 — such as when a family member or health care worker takes care of an infected person
• if you've recently travelled internationally or in contact with any person who travelled internationally and have COVID-19 symptoms and you've possibly been exposed to the virus, contact to nearest health care facility right away to conform that.

Diagnostic Evaluation

• History collection
• Physical examination
• Vital signs (to find fever status)
• Chest x-ray (should take both lungs)
• Blood test (mostly white blood count low)
• laboratory testing for COVID-19 (for conformation)
• Real-Time RT-PCR Panel for Detection 2019-Novel Coronavirus.
• After initial confirmation of COVID-10, additional testing of clinical specimens can help inform clinical management, including discharge planning.

Prevention from Novel Coronavirus

• Currently, there is no vaccine to prevent coronavirus disease 2019 (COVID-19).
• To prevent illness, the best way is to avoid being exposed to this virus.
• Everyday preventive actions that can help us to prevent the spread of respiratory diseases and COVID-19, including:
• Avoid close contact with anyone who is sick.
• Avoid touching your eyes, nose and mouth if your hands aren't clean.
• Stay home from work, school and public areas if you're sick.
• Cover your mouth and nose with your elbow or use tissue paper when you cough or sneeze.
• Avoid sharing dishes, glasses, bedding and other household items if you're sick.
• Clean and disinfect frequently touched objects and surfaces using a regular household cleaning spray or wipe.
• Always wash hands if hands are visibly dirty. Wash with soap and water, or use an alcohol-based hand sanitizer with at least 60% alcohol.
• Wash your hands often with soap and water for at least 20 seconds, especially after going to the bathroom; before eating; and after blowing your nose, coughing, or sneezing.
• Wear facemask
• when you are sick.
• The use of facemasks is crucial for health workers and people who are taking care of someone in close settings (at home or in a health care facility).
• CDC does not recommend the use of facemask to that people who are well to protect themselves from respiratory diseases, including COVID-19.
• Facemasks should be used by people who show symptoms of COVID-19 to help prevent the spread of the disease to others.
• WHO also recommends that -
• Avoid eating raw or undercooked meat or animal organs.
• Avoid contact with live animals and surfaces they may have touched if you're visiting live markets in areas that have recently had new coronavirus cases.

Management

• Currently, no specific treatment is available to treat COVID-19.
• Clinical management includes prompt implementation of recommended infection prevention and control measures and only can supportive symptomatic pharmacological management for complications, including advanced organ support if indicated.
• For recommendations on discontinuation of transmission-based precautions or home isolation for patients who have recovered from COVID-19 illness, please see: Interim Guidance for Discontinuation of Transmission-Based Precautions and Disposition of Hospitalized Patients with COVID-19 and Interim Guidance for Discontinuation of In-Home Isolation for Patients with COVID-19.

References

1. CDC. Coronavirus Disease 2019 (COVID-19) [Internet]. Centers for Disease Control and Prevention. 2020 [cited 2020 Mar 8]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html
2. CDC, CDC. Coronavirus Disease 2019 (COVID-19) – Prevention & Treatment [Internet]. Centers for Disease Control and Prevention. 2020 [cited 2020 Mar 8]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/about/prevention-treatment.html
3. staff familydoctor org editorial. Coronavirus: Symptoms, Diagnosis, Treatment [Internet]. familydoctor.org. [cited 2020 Mar 8]. Available from: https://familydoctor.org/condition/coronavirus/
4. 2019 Coronavirus (COVID-19): Symptoms,Treatment, Prevention [Internet]. Healthline. [cited 2020 Mar 8]. Available from: https://www.healthline.com/health/coronavirus-covid-19
5. Coronavirus [Internet]. [cited 2020 Mar 8]. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019
6. Coronavirus disease 2019 (COVID-19) - Symptoms and causes [Internet]. Mayo Clinic. [cited 2020 Mar 8]. Available from: https://www.mayoclinic.org/diseases-conditions/coronavirus/symptoms-causes/syc-20479963
7. Coronavirus LIVE News: Kerala reports five cases, boy from US under observation in TN [Internet]. The Economic Times. [cited 2020 Mar 8]. Available from: https://economictimes.indiatimes.com/news/politics-and-nation/coronavirus-cases-in-india-live-news-latest-updates-march8/liveblog/74533917.cms
8. Myth busters [Internet]. [cited 2020 Mar 8]. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/myth-busters

कोरोना वाइरस 2019 (COVID-19)

नॉवेल कोरोना वायरस (2019-nCoV) चीन के हुबेई प्रांत के वुहान शहर में सांस की बीमारी का प्रकोप के रूप मे पैदा हुआ। वुहान और अन्य चीनी शहरों के आलावा  COVID-19 वैश्विक स्तर पर लगभग 70 से अधिक देशों पर फैल गया है और इससे लगभग 1.35 लाख से अधिक लोग इससे संक्रमित पाए गए है और उनमे से 3500 से अधिक लोगो की जान चली गयी।

भारत में, COVID-19 मामलों की पुष्टि केरल, दिल्ली, उत्तर प्रदेश, राजस्थान, तमिलनाडु एवं जम्मू और कश्मीर राज्य में की गई है। अभी तक कुल 39 मामलों की पुष्टि की गई, जिनमें से केरल राज्य के 3 व्यक्तियों को ठीक किया गया और अभी तक  किसी भी मौत की सूचना नहीं मिली है।

कोरोना वायरस

कोरोनावायरस वायरस का एक परिवार है जो आम सर्दी जुकाम जैसी बीमारियों का कारण बनता है। इस परिवार में छह प्रकार के वायरस हैं।

1. मानव कोरोना वायरस 229 इ (एच.सीओ.वी-229 इ )
2. मानव कोरोना वायरस एनएल 63 (एच.सीओ.वी-एन.एल 63)
3. मानव कोरोना वायरस ओ. सी. 43 (एच.सीओ.वी-ओ. सी. 43)
4. मानव कोरोना वायरस एच.के.यू. 1 (एच.सीओ. वी-एच. के. यू. 1)
5. मध्य पूर्व श्वसन सिंड्रोम MERS कोरोना वायरस (ऍम.इ.आर.एस.-सीओ.वी)
6. गंभीर तीव्र श्वसन सिंड्रोम SARS कोरोना वायरस (एस .ऐ .आर.एस.-सीओ.वी)
7. नॉवेल कोरोनावायरस (2019-nCoV) को अब 2019 में सातवें नए कोरोनावायरस के रूप में रिपोर्ट किया गया है।

फैलने का तरीका

यह अभी तक बिल्कुल स्पष्ट नहीं है कि नया कोरोना वायरस कितना संक्रामक है। आमतौर पर, यह जानवरों में पाया जाता है। दुर्लभ रूप से, यह जानवरों से मनुष्यों में फेल सकता है। एक बार जब मनुष्य इससे संक्रमित हो जाता है तो यह एक व्यक्ति से दूसरे व्यक्ति में फैल सीधे संपर्क मैं आने से फैलता है । यह संक्रमित व्यक्ति की खांसी या छींक की बूंदों से भी फैल सकता है।

रोग के लक्षण

• COVID-19 के लक्षण संक्रमित होने के 2 से 14 दिन बाद दिखाई दे सकते हैं। इसके लक्षणभी अन्य श्वसन बीमारियों जैसे कि इन्फ्लूएंजा और सामान्य सर्दी के साथ बहुत समान होते है। इसके लक्षणो में बुखार, थकान और सूखी खांसी, सांस की तकलीफ, श्वसन संकट (रेस्पिरेटरी डिस्ट्रेस) हो सकते है।
• COVID-19 लक्षणों की गंभीरता बहुत हल्के से लेकर गंभीर तक हो सकती है। जो लोग अधिक उम्र के हैं और उनमे कोई लम्बी पुराणी बीमारी जैसे कि फेफड़े की बीमारी, कैंसर, हृदय की विफलता, सेरेब्रोवास्कुलर रोग, गुर्दे की बीमारी, यकृत की बीमारी, मधुमेह और जिनमे रोग प्रतिरोधक क्षमता कम हो और गर्भावस्था में हो, इन सभी मैं संक्रमित होने की सम्भावना अधिक होती हैं।
• जिन देशो में COVID-19 फैला हुआ है उन देशो में हाल की यात्रा किया हुआ व्यक्ति या वह का निवास  संपर्क  - जैसे कि जब कोई परिवार का सदस्य या स्वास्थ्य देखभाल कार्यकर्ता संक्रमित व्यक्ति की देखभाल करता है तो इन में भी संक्रमित होने की सम्भावना अधिक होती हैं।
• यदि आपने हाल ही में अंतरराष्ट्रीय स्तर पर यात्रा की है या किसी ऐसे व्यक्ति के संपर्क में आये है जिसने अंतरराष्ट्रीय स्तर पर यात्रा की है और उसमे  COVID-19 के लक्षण हैं तो आपको संभवतः वायरस की जांच के लिए निकटतम चिकित्सालय में तुरंत संपर्क करें।

नैदानिक ​​मूल्यांकन

• लक्षणों की जांच।
• शारीरिक जांच।
• छाती का एक्स-रे (दोनों फेफड़े लेना चाहिए)।
• खून की जांच  (ज्यादातर सफेद रक्त कणिकाओं की  गिनती)।
• COVID-19 के लिए प्रयोगशाला परीक्षण।

कोरोन वायरस (COVID-19) से रोकथाम

• वर्तमान में, कोरोन वायरस वायरस 2019 को रोकने के लिए कोई टीका नहीं है। बीमारी को रोकने के लिए, इस वायरस के संपर्क में आने से बचना ही सबसे अच्छा तरीका है। प्रतिदिन की क्रियाएं जो सांस की बीमारियों और COVID-19 के प्रसार को रोकने में हमारी मदद कर सकती हैं, जिनमें शामिल हैं-
• जो भी बीमार है उसके साथ निकट संपर्क  में आने से बचें।
• अगर आपके हाथ साफ नहीं हैं तो अपनी आंखों, नाक और मुंह को छूने से बचें।
• यदि आप बीमार हैं तो काम, स्कूल और सार्वजनिक क्षेत्रों पर  नहीं जाये, घर पर ही रहें।
• खांसी या छींक आने पर अपने मुंह और नाक को हाथो के बजाय कोहनी से ढके या टिशू पेपर का इस्तेमाल कर।
• यदि आप बीमार हैं तो  खाना, चश्मा, बिस्तर और अन्य घरेलू सामानों को साझा करने से बचें।
• नियमित रूप से घर की सफाई करे और पोंछे  में कीटाणुनाशक का उपयोग करके वस्तुओं और सतहों को अक्सर साफ और कीटाणुरहित करे।
• अगर हाथ गंदे है तो हमेशा हाथ साबुन और पानी से धोएं, या कम से कम 60% अल्कोहल-आधारित हैंड सैनिटाइज़र का उपयोग करें।
• अपने हाथों को अक्सर साबुन और पानी से कम से कम 20 सेकंड के लिए धोएं, खासकर बाथरूम जाने के बाद; खाने से पहले; और अपनी नाक साफ करने के बाद, खाँसने या छींकने के बाद।
• चेहरे पर मास्क पहनें
• जब भी आप बीमार होते हैं।
• मास्क का उपयोग स्वास्थ्य कार्यकर्ताओं और उन लोगों के लिए महत्वपूर्ण है, जो मरीजों की देखभाल कर रहे हैं।
• फेसमास्क का उपयोग उन लोगों द्वारा किया जाना चाहिए जिनमे COVID-19 के लक्षण दिखाते हैं क्योकि यह बीमारी के प्रसार को रोकने में मदद करता है, ना की इसके संक्रमित होने से बचाता है |
• डब्ल्यू.एच. ओ. की सिफारिश के अनुसार -
• कच्चे या अधपके मांस या जानवरों के अंगों को खाने से बचें।
• जीवित जानवरों और सतहों के संपर्क में आने से बचें, यदि आपने हाल ही में नए कोरोनो वायरस मामलों वाले क्षेत्रों में लाइव बाजारों का दौरा किया हो।

इलाज

वर्तमान में,  COVID-19  के लिए कोई विशिष्ट इलाज उपलब्ध नहीं है। इलाज के रूप  में अनुशंसित संक्रमण की रोकथाम और नियंत्रण उपायों का त्वरित कार्यान्वयन शामिल है और केवल जटिलताओं एवं वाइटल ऑर्गन सपोर्ट के लिए रोगसूचक औषधीय प्रबंधन  कर सकते है।

संदर्भ 

• CDC. Coronavirus Disease 2019 (COVID-19) [Internet]. Centers for Disease Control and Prevention. 2020 [cited 2020 Mar 8]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html
• CDC, CDC. Coronavirus Disease 2019 (COVID-19) – Prevention & Treatment [Internet]. Centers for Disease Control and Prevention. 2020 [cited 2020 Mar 8]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/about/prevention-treatment.html
• staff familydoctor org editorial. Coronavirus: Symptoms, Diagnosis, Treatment [Internet]. familydoctor.org. [cited 2020 Mar 8]. Available from: https://familydoctor.org/condition/coronavirus/
• 2019 Coronavirus (COVID-19): Symptoms,Treatment, Prevention [Internet]. Healthline. [cited 2020 Mar 8]. Available from: https://www.healthline.com/health/coronavirus-covid-19
• Coronavirus [Internet]. [cited 2020 Mar 8]. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019
• Coronavirus disease 2019 (COVID-19) - Symptoms and causes [Internet]. Mayo Clinic. [cited 2020 Mar 8]. Available from: https://www.mayoclinic.org/diseases-conditions/coronavirus/symptoms-causes/syc-20479963
• Coronavirus LIVE News: Kerala reports five cases, boy from US under observation in TN [Internet]. The Economic Times. [cited 2020 Mar 8]. Available from: https://economictimes.indiatimes.com/news/politics-and-nation/coronavirus-cases-in-india-live-news-latest-updates-march8/liveblog/74533917.cms
• Myth busters [Internet]. [cited 2020 Mar 8]. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/myth-busters

PNEUMONIA

Pneumonia is an inflammation of the lung parenchyma, involving the terminal airways and alveoli, leading to pulmonary consolidation because alveoli is filled with exudates.

Pneumonia may be divided into three groups:

• Community acquired, due to a number of organisms, including Streptococcus pneumoniae
• Hospital acquired (nosocomial), due primarily to gram-negative bacilli and staphylococci
• Pneumonia in the immunocompromised person

ETIOLOGY

Etiologic Agents

• Streptococcus pneumoniae – (Streptococcal/Pneumococcal Pneumonia)
• Staphylococcus aureus - Staphylococcal pneumonia
• Hemophilus influenzae (Haemophilus Influenza Pneumonia)
• Legionella pneumophila - Legionnaires' disease
• Others -
  •  
  • Klebsiella Pneumoniae,
  • Diplococcus Pneumoniae,
  • Escherichia Coli,
  • Pseudomonas Aeruginosa
  • Mycoplasma Pneumoniae,
  • Chlamydia Trachomatis
  • L. Pneumophila,
  • Rhinoviruses,
  • Adenovirus,
  • Varicella,
  • Rubella,
  • Rubeola,
  • Herpes Simplex,
  • Cytomegalovirus,
  • Epstein-Barr Virus
  • Aspergillus Fumigatus

 

High Risk Groups

• Children less than 5 year
• Elderly

Predisposing Factors

• Smoking
• Air pollution
• Immunocompromised
  • (+) AIDS
  • Kaposi's Sarcoma
  • Pneumocystis Carinii Pneumonia
  • Bronchogenic Carcinoma
• Prolonged immobility (hypostatic pneumonia)
• Aspiration of food (aspiration pneumonia)
• Over fatigue

Pathophysiology

SIGNS AND SYMPTOMS

• Sudden onset; shaking chill; rapidly rising fever of 101° F to 105° F.
• Productive cough with purulent sputum, greenish to rusty.
• Dyspnea, tachypnea with prolong expiratory grunt
• Pleuritic chest pain aggravated by respiration/coughing
• Nasal flaring, use of accessory muscles of respiration, fatigue
• Rapid, bounding pulse
• General body malaise
• Cyanosis
• Pleuritic friction rub
• Rales/crackles on auscultation
• Abdominal distention => paralytic ileus

Diagnostic Evaluation

• Chest X-ray - (+) pulmonary consolidation
• CBC - Elevated WBC and ESR
• ABG – PaO2 decreased (hypoxemia)
• Gram stain, culture & sensitivity tests of sputum-(+) to cultured microorganism
• Blood culture detects bacteremia
• Immunologic test detects microbial antigens in serum, sputum, and urine.

Complications

• Pleural effusion.
• Sustained hypotension and shock,
• Superinfection: pericarditis, bacteraemia, and meningitis.
• Delirium-this is considered a medical emergency.
• Atelectasis-due to mucous plugs.

Management

• Treatment algorithm for patient with suspected pneumonia

Becterial pneumonia

1. Antimicrobial therapy-depends on laboratory identification of causative organism and sensitivity to specific antimicrobials, or presumptive therapy with broad spectrum agent in milder cases.

• Macrolide antibiotics such as azithromycin or clarithromycin; doxycycline;
• Oral beta lactams such as cefuroxime, amoxicillin, or amoxicillin clavulanate.
• Cephalosporins;
• penicillinase-resistant extended-spectrum penicillins;
• vancomycin (Vancocin) for methicillin-resistant S. aureus

Viral pneumonia

• Treat symptomatically
• Amantadine (Symmetrel) relieves symptoms
• Prophylactic vaccination recommended for high-risk persons (over age 65; chronic cardiac or pulmonary disease, diabetes, and other metabolic disorders).

Fungal pneumonia

• Amphotericin B
• Itraconazole.

1. Oxygen therapy, if required.

Nursing Management

Nursing Assessment

• Take a careful history to help establish etiologic diagnosis.
  • History of recent respiratory illness including mode of onset
  • Presence of purulent sputum, increased amount of sputum, fever, chills, chest pain, dyspnea, tachypnea
  • Any family illness
  • Medications, alcohol, tobacco, or I.V. drug use
• Observe for anxious, flushed appearance, shallow respirations, splinting of affected side, confusion, disorientation.
• Auscultate for crackles overlying affected region, and for bronchial breath sounds when consolidation (filling of airspaces with exudate) is present.

Nursing Diagnoses

1. Impaired Gas Exchange related to decreased ventilation secondary to inflammation and infection involving distal airspaces
2. Ineffective Airway Clearance related to excessive tracheobronchial secretions
3. Acute Pain related to inflammatory process and dyspnea
4. Risk for Injury secondary to complications

Nursing Interventions

Improving Gas Exchange

• Observe for cyanosis, dyspnea, hypoxia, and confusion, indicating worsening condition.
• Follow ABG levels/Sao₂ to determine oxygen need and response to oxygen therapy.
• Administer oxygen at concentration to maintain Pao₂ at acceptable level.
• Avoid high concentrations of oxygen in patients with COPD, particularly with evidence of CO₂ retention. If high concentrations of oxygen are given, monitor alertness and PaO₂ and PaCO₂ levels for signs of CO₂ retention.
• Place patient in an upright position to obtain greater lung expansion and improve aeration. Frequent turning and increased activity (up in chair, ambulate as tolerated) should be employed.

Enhancing Airway Clearance

• Obtain freshly expectorated sputum for gram stain and culture, preferably early morning specimen as directed. Instruct the patient as follows:
  • Rinse mouth with water to minimize contamination by normal flora.
  • Breathe deeply several times.
  • Cough deeply and expectorate raised sputum into sterile container.
• Encourage patient to cough; retained secretions interfere with gas exchange.
• Encourage increased fluid intake, unless contraindicated, to thin mucus and promote expectoration and replace fluid losses caused by fever, diaphoresis, dehydration, and dyspnea.
• Humidify air or oxygen therapy to loosen secretions and improve ventilation.
• Employ chest wall percussion and postural drainage when appropriate to loosen and mobilize secretions.
• Auscultate the chest for crackles and rhonchi.
• Administer cough suppressants when coughing is non-productive only if there is no evidence of retained secretions.
• Mobilize patient to improve secretion clearance and reduce risk of atelectasis and worsening pneumonia.

Relieving Pleuritic Pain

• Place in a comfortable position (semi-Fowler's) for resting and breathing.
• Encourage frequent change of position to prevent pooling of secretions in lungs.
• Avoid suppressing a productive cough.
• Administer prescribed analgesic agent to relieve pain. Avoid opioids in patients with a history of COPD.
• Apply heat and/or cold to chest as prescribed.
• Encourage modified bed rest during febrile period.
• Watch for abdominal distention or ileus, which may be due to swallowing of air during intervals of severe dyspnea. Insert a nasogastric (NG) or rectal tube as directed.

Monitoring for Complications

• Remember that fatal complications may develop during the early period of antimicrobial treatment.
• Monitor temperature, pulse, respiration, blood pressure, and oximetry at regular intervals to assess the patient's response to therapy.
• Auscultate lungs and heart. Heart murmurs or friction rub may indicate acute bacterial endocarditis, pericarditis, or myocarditis.
• Employ special nursing surveillance for patients with:
  • Alcoholism, COPD, immunosuppression-these people as well as elderly patients, may have little or no fever.
  • Chronic bronchitis-it is difficult to detect subtle changes in condition, because the patient may have seriously compromised pulmonary function.
  • Epilepsy-pneumonia may result from aspiration after a seizure.
  • Delirium-may be caused by hypoxia, meningitis, delirium tremens of alcoholism.
• Assess these patients for unusual behaviour, alterations in mental status, stupor, and heart failure.
• Assess for resistant fever or return of fever, potentially indicating bacterial resistance to antibiotics.

Health Education

• Advise patient that fatigue, weakness, and depression may be prolonged after pneumonia.
• Encourage chair rest after fever subsides; gradually increase activities to bring energy level back to preillness stage.
• Encourage breathing exercises to clear lungs and promote full expansion and function after the fever subsides.
• Explain that a chest X-ray is taken 4 to 6 weeks after recovery to evaluate lungs for clearing and detect any tumour or underlying cause.
• Advise smoking cessation. Cigarette smoke destroys tracheobronchial cilial action, which is the first line of defense of lungs; also irritates mucosa of bronchi and inhibits function of alveolar scavenger cells (macrophages).
• Advise the patient to keep up natural resistance with good nutrition, adequate rest. One episode of pneumonia may make the patient susceptible to recurring respiratory infections.
• Instruct patient to avoid fatigue, sudden extremes in temperature, and excessive alcohol intake, which lower resistance to pneumonia.
• Encourage yearly immunization for influenza and S. pneumoniae, a major cause of bacterial pneumonia.
• Advise avoidance of contact with people who have upper respiratory infections for several months after pneumonia resolves.
• Practice frequent handwashing, especially after contact with others.

RESPIRATORY FAILURE

• Respiratory failure is not really a disease; it is a general term to describe any circumstance that interferes with the ability to maintain adequate gas exchange.
• Respiratory failure is defined as a life threatening condition of an alteration in an individual's oxygenation (PaO₂) to fall below 60 mm Hg (hypoxemia) and/or the partial pressure of arterial carbon dioxide (PaCo₂) to rise above 50 mm Hg (hypercapnia), on room air as determined by arterial blood gas (ABG) analysis.
• It is considered to exist when the respiratory system is no longer able to meet metabolic demand.

Classification

Respiratory failure classified as acute or chronic.

Acute Respiratory Failure

1. Characterized by hypoxemia (Pao₂ less than 50 mm Hg) and/or hypercapnia (Paco₂ greater than 50 mm Hg) and acidemia (pH less than 7.35).
2. Occurs rapidly, usually in minutes to hours or days.

Chronic Respiratory Failure

1. Characterized by hypoxemia (decreased Pao₂) and/or hypercapnia (increased Paco₂) with a normal pH (7.35 to 7.45).
2. Occurs over a period of months to years-allows for activation of compensatory mechanisms.

Etiology / Types

There are two different types of respiratory failure.

Type I - hypoxemic respiratory failure - is also known as Oxygenation Failure; in this type, oxygenation is compromised but carbon dioxide levels may be either normal or low. (Hypoventilation with V/Q mismatch)

• Decreased alveolar oxygenation

  Influenced by many factors, including conditions modifying environmental oxygen tension

  • Affected by altitude - FiO₂ reduces to less than 21%
  • Fire - consume the environmental oxygen
  • Oxygen supplementation
• Ventilation/perfusion (V/Q) mismatch

  Affected by factors such as bronchoconstriction, the presence of secretions in the airway and the surface area of the alveoli.

  • Atelectasis (alveolar collapse) decreases surface area,
  • Emphysema and fluid within the alveoli
  • Pulmonary artery vasospasm and
  • Pulmonary embolism
  • Hypoxia, hypoxic pulmonary vasoconstriction
  • Cardiogenic pulmonary edema (left ventricular failure; mitral stenosis).
  • Acute respiratory distress syndrome (ARDS)
• Decreased oxyhaemoglobin saturation

  Apart from the factors impeding gas exchange, other influences can affect the amount of oxygen binding to haemoglobin.

  • Carbon monoxide poisoning

Type II - Hypercapnia respiratory failure - is also known as ventilatory failure; in this type, both oxygenation and carbon dioxide elimination are compromised. (Hypoventilation with or without V/Q mismatch)

Ventilatory Failure with Normal Lungs

• Decreased central ventilatory drive

  Conditions that alter the respiratory drive include -

  • Brain stem compression from haemorrhage or tumour,
  • Metabolic encephalopathy and
  • Overdose of depressant drugs, such as anaesthetic agents, narcotics or benzodiazepines.
• Decreased neuromuscular transmission

  Conditions affecting the neuromuscular units supplying respiratory muscles include

  • Spinal cord injury,
  • Multiple sclerosis,
  • Myasthenia gravis and
  • Gullain-barré syndrome.
  • Drugs with neuromuscular junction antagonistic affects can also cause ventilatory failure.
• Chest wall or muscle pathology

  Conditions that affect respiratory muscles include

  • Fatigue,
  • Disuse atrophy,
  • Polymyositis and
  • Muscular dystrophy.
  • Flail chest,
  • Kyphoscoliosis,
  • Morbid obesity
  • Pneumothorax

Ventilatory Failure with Intrinsic Lung Disease

• Intrinsic Lung Disease
  • Chronic obstructive pulmonary disease (COPD) (chronic bronchitis, emphysema).
  • Severe asthma.
  • Cystic fibrosis.

Pathophysiology

Clinical Manifestations

• Hypoxemia-restlessness, agitation, dyspnoea, disorientation, confusion, delirium, loss of consciousness.
• Hypercapnia-headache, somnolence, dizziness, confusion.
• Tachypnea initially; then when no longer able to compensate, bradypnea
• Accessory muscle use
• Asynchronous respirations

Diagnostic Evaluation

• ABG analysis-show changes in PaO2, PaCO2, and pH from patient's normal; or PaO2 less than 50 mm Hg, PaCO2 greater than 50 mm Hg, pH less than 7.35.
• Pulse oximetry-decreasing SaO2.
• End tidal CO2 monitoring-elevated.
• Complete blood count, serum electrolytes,
• chest X-ray,
• Urinalysis,
• Electrocardiogram (ECG),
• Blood and sputum cultures-to determine underlying cause and patient's condition.

Management

• Oxygen therapy to correct the hypoxemia.
• Chest physical therapy and hydration to mobilize secretions.
• Bronchodilators and possibly corticosteroids to reduce bronchospasm and inflammation.
• Diuretics for pulmonary congestion.
• Mechanical ventilation as indicated. Non-invasive positive-pressure ventilation using a facemask may be a successful option for short-term support of ventilation.

Note- Avoid administration of oxygen at Fio₂ of 100% for COPD patients because you may depress the respiratory center drive. For COPD patients, the drive to breathe may be hypoxemia.

Complications

1. Oxygen toxicity if prolonged high Fio₂ required.
2. Barotrauma from mechanical ventilation intervention

Nursing Management

Nursing Assessment

• Assess changes suggesting –
  • increased work of breathing - tachypnea, diaphoresis, intercostal muscle retraction, fatigue
  • Pulmonary edema - fine, coarse crackles or rales, frothy pink sputum.
• Assess breath sounds.
• Assess level of consciousness (LOC) and ability to tolerate increased work of breathing.
• Assess for signs of hypoxemia and hypercapnia.
• Determine vital capacity (VC), respiratory rate, and negative inspiratory force (NIF) and compare with values indicating need for mechanical ventilation:
• Analyse ABG and compare with previous values.
• Determine hemodynamic status (blood pressure, pulmonary wedge pressure, cardiac output, SvO2) and compare with previous values. If patient is on mechanical ventilation and positive end-expiratory pressure (PEEP), venous return may be limited, resulting in decreased cardiac output.

Nursing Diagnoses

1. Impaired Gas Exchange related to inadequate respiratory center activity or chest wall movement, airway obstruction, and/or fluid in lungs

• Goal: Improving Gas Exchange
• Administer antibiotics, cardiac medications, and diuretics as ordered.
• Administer oxygen to maintain PaO₂ of 60 mm Hg or SaO₂ > 90%.
• Monitor fluid balance by intake and output measurement.
• Provide measures to prevent atelectasis and promote chest expansion and secretion clearance.
• Monitor adequacy of alveolar ventilation by frequent measurement of respiratory rate, VC, inspiratory force, and ABG levels.
• Prepare to assist with non-invasive ventilation or intubation and initiation of mechanical ventilation, if indicated.

1. Ineffective Airway Clearance related to increased or tenacious secretions.

• Goal: Maintaining Airway Clearance
• Administer medications to increase alveolar ventilation-bronchodilators.
• Perform chest physiotherapy to remove mucus.
• Administer I.V. fluids and mucolytics to reduce sputum viscosity.
• Suction patient as needed to assist with removal of secretions.
• If the patient becomes increasingly lethargic, cannot cough or expectorate secretions, cannot cooperate with therapy, or if pH falls below 7.30, despite use of the above therapy, report and prepare to assist with intubation and initiation of mechanical ventilation.

Health Education

• Instruct patient with pre-existing pulmonary disease to seek early intervention for infections to prevent acute respiratory failure.
• Teach patient about medication regimen.
  • Proper technique for inhaler use
  • Dosage and timing of medications
  • Monitoring for adverse effects of corticosteroids: weight gain due to fluid retention, polyuria and polydipsia due to hyperglycemia, mood changes; report to health care provider

BRONCHIECTASIS

Bronchiectasis is a chronic irreversible dilatation of the bronchi and bronchioles due to inflammation and destruction of their walls and is generally associated with chronic lung infection and impaired airway defences.

Etio-Pathophysiology

Clinical Manifestations

• Persistent cough with production of copious amounts of purulent sputum.
• Dyspnea
• Cyanosis
• Finger clubbing
• Anorexia and generalized body malaise
• Recurrent fever and bouts of pulmonary infection
• Crackles and rhonchi heard over involved lobes
• Intermittent hemoptysis; breathlessness (only COPD with sign)

Diagnostic Evaluation

• ABG analysis reveals low PaO₂
• Bronchoscopy – direct visualization of bronchi lining using a fiberscope
• Chest X-ray may reveal areas of atelectasis with widespread dilatation of bronchi.
• Sputum examination may detect offending pathogens.
• High-resolution CT scan is useful in diagnosis of bronchiectasis.

Management

Goal: prevent progression of disease.

• Infection controlled by:
  • Smoking cessation.
  • Prompt antimicrobial treatment of exacerbations of infection.
  • Immunization against potential pulmonary pathogens (influenza and pneumococcal vaccine).
• Secretion clearance techniques, such as postural drainage, percussion and vibration or other methods.
• Bronchodilators for bronchodilation and improved secretion clearance.
• Surgical resection-when conservative management fails.
• Segmental lobectomy
• Pneumonectomy

Complications

• Progressive suppuration.
• Major pulmonary hemorrhage.
• COPD
• Atelectasis (post-surgical)
• Cardiac tamponade (post-surgical)

Nursing Management

• Encourage use of chest physical therapy techniques to empty the bronchi of accumulated secretions.
  • Assist with postural drainage positioning for involved lung segments to drain the bronchiectatic areas by gravity, thus reducing degree of infection and symptoms.
  • Use percussion and vibration to assist in mobilizing secretions.
  • Encourage productive coughing to help clear secretions.
• Consider vaporizer to provide humidification and keep secretions thin.
• Enforce Complete bed rest
• Low inflow O2 admin; (high inflow will cause respiratory arrest)
• Administer medications as ordered
  • Bronchodilators
  • Antimicrobials
  • Corticosteroids (5-10 minutes after bronchodilators)
  • Mucolytics/expectorants
• Encourage increased intake of fluids to reduce viscosity of sputum and make expectoration easier.
• Nebulize and suction client as needed
• Provide comfortable and humid environment

Health teaching

• Avoidance of smoking
• Prevent complications
  • Atelectasis
  • CO₂ narcosis => coma
  • Cor pulmonale
  • Pleural effusion
  • Pneumothorax
• Regular adherence to medications
• Importance of follow up care