Acute bronchitis frequently is an extension of an upper respiratory infection involving the trachea (tracheobronchitis) and is usually viral in origin. Other causes of acute bronchitis include inhalation of physical or chemical agents such as dust, automobile exhaust, industrial fumes, and tobacco smoke.

Early symptoms of acute bronchitis are similar to those of the common cold. In acute bronchitis, the symptoms progress to chest pain, fever, and a dry, hacking, and irritating cough. Later the cough becomes more productive of mucopurulent sputum. The fever may be moderate (≤101° F [38° C]) and accompanied by chills, muscle soreness, and headache. The physician relies on history and signs and symptoms for diagnosis.

Symptomatic treatment includes humidification using either warm or cool moist air. Cough mixtures or bronchodilators are used to reduce coughing and soothe the irritated tracheal and bronchial mucosa. Nutrition and fluid balance should be maintained. Rest is recommended to avoid progression from an acute condition to a chronic one. Antibiotics are used if a sputum culture shows specific organisms.

Influenza

Etiology

Influenza is an acute, highly infectious disease of the upper and lower respiratory tracts that occurs in isolated cases or in epidemics. Every year there are between 25 and 50 million cases resulting in more than 200,000 hospitalizations and between 30,000 and 40,000 deaths. Influenza is caused by three major types (A, B, and C) and numerous subtypes of influenza viruses. Type A is the most virulent and usually affects young adults first and then spreads to the very young and very old in the community. Influenza is spread by direct and indirect contact with infected people by coughing and sneezing and by virus transferred from contaminated hands to objects.

There are emerging infectious diseases that cause flulike symptoms (Box 15-1). Severe acute respiratory syndrome (SARS) appears to be spread by person-to-person contact, whereas avian flu and West Nile virus are spread by vectors such as certain birds and mosquitoes (Centers for Disease Control and Prevention [CDC], 2010).

Box 15-1

Emerging Infectious Diseases that May Cause Influenza Symptoms

Avian Flu

A pandemic of avian influenza that could kill millions of people is a worldwide fear. Vaccines are under development, but there is no effective vaccine yet. This type of bird flu had been restricted to poultry, but between 2003 and 2010 there were 495 confirmed cases and 292 deaths primarily in Southeast Asia and Africa (World Health Organization, 2010). All of these people had direct contact with infected poultry or secretions or excretions from poultry. Because there is no previous exposure to the virus, and consequently no built-up immunity, it can kill quickly. Symptoms are the same as for common influenza—fever, cough, sore throat, and muscle aches. Complications of pneumonia with acute respiratory distress syndrome have caused death. The drug oseltamivir (Tamiflu) is the only treatment available to decrease the severity of the disease. It is not known how effective this drug would be in a large outbreak.

To prevent the possibility of contracting avian flu, it is recommended to avoid areas where poultry are raised or kept; to not mingle with wild birds by feeding wild ducks, geese, or swans; and to be certain any poultry eaten is thoroughly cooked. Perform hand hygiene frequently and keep your hands away from your mouth, nose, and eyes.

H1N1

H1N1 (formerly known as swine flu) is a respiratory disease that occurs in pigs. The disease is usually passed from infected pigs to humans; however, human-to-human transmission has occurred when people are in close contact. The symptoms of swine flu are very similar to seasonal influenza. In spring 2009, there was public concern because Mexico reported deaths attributed to the H1N1 virus. At that time, travel to Mexico was not recommended. It was determined that the disease actually has a low mortality rate (1% to 4%); however, the possibility of a pandemic does exist if the virus were to become proficient at human-to-human transmission because most people do not have any natural immunity to H1N1.

The prevention measures are similar to avian flu. Avoid traveling to areas of known outbreaks. Avoid areas where swine are raised or kept. Cooking pork thoroughly will kill the virus. Perform hand hygiene and avoid touching the mouth, nose, or eyes. In September 2009, Novel H1N1 influenza A vaccine was approved by the Food and Drug Administration (FDA). Initial target groups for the vaccine included pregnant women, household contacts for children under 6 months of age, persons aged 6 months to 24 years, health care personnel, and adults 25 to 64 years old with underlying conditions that increase their risk for influenza.

West Nile Virus

West Nile virus (WNV) is transmitted by bites from infected mosquitoes. Most WNV infections are mild and inconsequential. The incubation period is 3 to 7 days. West Nile virus may cause flulike symptoms lasting up to 6 days. Symptoms include febrile illness with sudden onset malaise, anorexia, nausea, vomiting, headache, myalgia (muscle ache), eye pain, and lymphadenopathy. A rash may occur. The chances of becoming ill from one mosquito bite are very small. In about 1 in 150 instances of infection, the patient develops encephalitis, a severe neurologic disease. This occurs mostly in patients of advanced age. High fever and changing mental status are the initial signs. Treatment of severe disease is supportive, with hospitalization, intravenous fluids, respiratory support, and prevention of secondary infection.

Prevention of WNV is to avoid mosquito bites. Avoid being outdoors at dawn and dusk. When outside, wear a long-sleeved shirt, long pants, and socks with shoes and spray exposed skin and clothing with an insect repellent containing DEET. Keep containers around the yard empty of standing water. Use screens on open windows and doors.

Severe Acute Respiratory Syndrome

Severe acute respiratory syndrome (SARS) is caused by a previously unrecognized SARS-associated coronavirus (SARS-CoV). The disease first appeared as a global threat in 2003 and affected people ages 25 to 70 years. The illness begins with fever >100.4° F (>38° C) that may be accompanied by chills, headache, malaise, and body aches. For those infected, 10% to 20% develop diarrhea. Within 2 to 7 days, a dry cough or dyspnea occurs. Most patients develop pneumonia, and hypoxemia can progress to the need for mechanical ventilation.

SARS appears to be spread by close person-to-person contact, and is thought to be transmitted mostly by respiratory droplets via coughs and sneezes. It is possible that SARS is spread through the air, or by other ways not yet known. The severity of SARS ranges from mild illness to death. Supportive treatment and medications used for pneumonia are given. Antiviral agents may be added, but there is no known specific treatment for this disorder. Use of Standard Precautions and isolation precautions as specified by the facility would be initiated.

Pathophysiology

The influenza viruses affect the respiratory mucosa, causing inflammation and necrosis of tissue and shedding of the virus into the secretions. The inflammation may involve the lungs, pharynx, sinuses, and eustachian tubes. The necrotic tissue provides an environment for the growth of bacteria that cause secondary infection.

Signs and Symptoms

The first symptoms of influenza appear suddenly 2 to 3 days after exposure and include headache, fever (often 101° to 103° F [38° to 40° C]), chills, and muscle aches. Sore throat, hacking cough, runny nose, and nasal congestion and light sensitivity, nausea, vomiting, and diarrhea can also occur.

Diagnosis

Chest radiographs and auscultation usually show no abnormality. The white cell count is normal or slightly below normal. Diagnosis is usually based on clinical findings. To confirm the diagnosis, viral culture, serology, rapid antigen testing, or polymerase chain reaction and/or immunofluorescence assays must be performed.

Treatment and Nursing Management

Antibiotics are given only if there is evidence of bacterial infection secondary to the viral infection. If a person is known to be at high risk for influenza and has been exposed to type A influenza, the physician may choose to provide prophylaxis with an antiviral agent such as amantadine (Symmetrel), rimantadine (Flumadine), zanamivir (Relenza), or oseltamivir (Tamiflu). These drugs must be started within 48 hours of the start of symptoms.

Safety Alert

Warnings About Antiviral Medications

The U.S. Food and Drug Administration (FDA) has issued warnings that oseltamivir (Tamiflu) and zanamivir (Relenza) may cause neurologic and behavioral problems, such as hallucinations, delirium, abnormal behavior, and fatalities. Monitor for and report these changes to the primary care physician. Teach your patients to observe for and report problems. Be aware that additional research about these medications is planned.

Uncomplicated influenza usually is managed more effectively by nursing intervention than by drugs or other forms of medical treatment. Nursing interventions for patients with flu symptoms might include:

• Increase oral fluid intake to at least 3000 mL per 24 hours, unless contraindicated.

• Encourage patient to take analgesics when discomfort first appears.

• Saline gargles for a sore throat.

• Administer suppressant cough medicine at bedtime and during the night as prescribed.

• Perform mouth care at least every 4 hours, before each meal, and more frequently if patient reports bad taste in mouth or has halitosis from sputum.

• Cater to patient’s food and drink preferences within limits of dietary restrictions.

• Give antipyretics and perform sponge bath and other measures to reduce high fever.

• Humidify inhaled air.

• Splint chest and abdomen with pillow during coughing attacks.

• Apply emollient to lips and nares as needed.

• Clear nostrils as much as possible to prevent mouth breathing.

• Provide for periods of uninterrupted rest.

• Protect from and monitor for secondary infections such as pneumonia, otitis media, and sinusitis, as the weakened immune system causes greater susceptibility.

Health Promotion

Protection from Influenza

The Advisory Committee on Immunization Practices (2009) recommends annual influenza vaccination for the following groups: (CDC, 2009).

• People at high risk for influenza-related complications and severe disease, including:

• Children ages 6 to 59 months

• Pregnant women

• People age >50 years

• People of any age with certain chronic medical conditions

• People who live with or care for persons at high risk, including:

• Household contacts who have frequent contact with people at high risk and who can transmit influenza to those individuals

• Health care workers

Complementary and Alternative Therapies

Alternative Therapy for the “Flu”

Elderberry extract has been used for centuries as a treatment to ease symptoms of the flu, colds, and sinus infections. It seems to prevent the influenza virus from latching onto cells. There are antioxidants found in the purple elderberry fruit that have an anti-inflammatory effect comparable to aspirin. This may explain why the juice produces symptom improvement (Long, 2011).

Pneumonia

Etiology and Pathophysiology

Pneumonia is an extensive inflammation of the lung with either consolidation of the lung tissue as it fills with exudate or interstitial inflammation and edema. It can affect one or both lungs or only one lobe of a lung (lobar pneumonia). In 2006, 55,477 people died of pneumonia; it is the eighth leading cause (combined with influenza) of death in the United States (American Lung Association, 2010a). Pneumonia is classified as community acquired or hospital acquired. Viral pneumonia does not produce exudate; it causes interstitial inflammation and it tends to be less severe than bacterial pneumonia. Bacterial pneumonia usually produces exudate leading to consolidation. It most commonly affects only one lung. Streptococcus pneumoniae (pneumococcus) is the most common cause of bacterial pneumonia. Pathogenic microorganisms are always present in the upper respiratory tract; pneumonia can occur when resistance is lowered by some other factor, such as chronic disease, alcoholism, debilitation, physical inactivity, or extremes in age (very young or very old). Pneumonia frequently occurs after an influenza infection. Concept Map 15-1 presents the pathophysiology of pneumonia.

Concept Map 15-1 Pathophysiology of pneumonia.

Pneumonia also can result from inhalation of irritating gases (chemical pneumonia) or accidental aspiration of foods or liquids that cause a pneumonitis progressing to pneumonia (aspiration pneumonia). Hypostatic pneumonia results from lying in bed for extended periods because of lack of physical exercise and inadequate aeration of the lungs. Fungi also may cause opportunistic pneumonia in immunocompromised patients. Cytomegalovirus has become a cause of pneumonia in immunocompromised patients, particularly those with AIDS or transplant patients on immunosuppressive drugs.

Prevention

People over age 65, and those with chronic respiratory disease, should receive Pneumovax, the pneumococcal pneumonia vaccine. A second dose may be needed 5 years after the first dose for immunocompromised patients or those over 65 years.

A variety of nursing interventions can help prevent pneumonia, including:

• Strengthening the patient’s natural defenses and avoiding infection.

• Ensuring frequent turning, coughing, and deep breathing for postoperative patients or those who are otherwise unable to ventilate their lungs adequately.

• Watching for vomiting and initiating a side-lying position for patients with decreased consciousness, such as patients recovering from anesthesia.

• Elevating the head of the bed when assisting with meals or administering tube feedings and leaving the head elevated for 30 to 60 minutes afterward to prevent aspiration. Check residual before each feeding, or once every 4 hours (Eisenstadt, 2010).

• Avoiding thin liquids for patients who are at risk for aspiration.

• Faithfully following principles of cleanliness and asepsis when caring for debilitated patients and those most susceptible to infection.

• Encouraging pneumonia vaccine for those most at risk for developing the disease.

• Encouraging immunization against influenza.

Cultural Considerations

Ethnic Considerations for Pneumococcal Vaccine

The Advisory Committee on Immunization Practices (CDC, 2009) has recently clarified that routine use of pneumococcal polysaccharide vaccine is not recommended for persons of Alaskan Native or American Indian heritage unless they have underlying medical conditions such as chronic lung, liver, or renal disease. However, local public health authorities may consider recommending the vaccine for occurrences of increased risk.

Patients are at risk for health care–associated pneumonia (HCAP) (formerly known as nosocomial pneumonia). These at-risk circumstances include hospital-acquired pneumonia (HAP) where symptoms occur more than 48 hours after admission or ventilator-associated pneumonia (VAP) where pneumonia occurs 48 to 72 hours after endotracheal intubation. HCAP is also associated with nursing home or long-term care; intravenous therapy, chemotherapy, immunosuppressive treatment, or wound care; severe chronic obstructive pulmonary disease (COPD); or child care facilities, hospitals, or dialysis centers (Atkinson, 2010). HAP is a major problem that lengthens hospital stays and increases the cost of health care. VAP is the second most common hospital-acquired infection; however, vigilant and aggressive nursing and respiratory care can greatly decrease the incidence.

People who are on gastrointestinal acid–suppressive therapy should be educated that this may make them more susceptible to community-acquired pneumonia (Restrepo et al., 2010). Normal gastric acid helps prevent pathogens from colonizing the upper GI tract, where they can then be introduced into the respiratory tract.

Signs, Symptoms, and Diagnosis

In typical infectious pneumonia, there is usually a high fever accompanied by chills, a cough that produces rusty or blood-flecked sputum, sweating, chest pain that is made worse by respiratory movements, and a general feeling of malaise and aching muscles. Diagnosis is confirmed by chest radiograph, which reveals densities in the affected lung.

In atypical pneumonia, body temperature can be normal or subnormal, breath sounds can be normal with perhaps only occasional crackles and wheezes, and there may be no pleural involvement and therefore no pain, dry cough, or feeling of extreme fatigue. Chest radiography reveals diffuse, patchy areas of density.

Treatment

Typical pneumonia is treated with intravenous (IV) or oral antibiotic agents, such as erythromycin or the new macrolides (clarithromycin [Biaxin]), cephalosporins, aminoglycosides, or fluoroquinolones such as ciprofloxacin (Cipro).

Atypical pneumonia caused by Mycoplasma species usually is treated with either erythromycin, clarithromycin, or azithromycin. Viral, atypical pneumonia requires no anti-infective therapy, but antiviral medication may be administered. Pneumocystis jiroveci infection associated with AIDS is treated with aerosolized and intravenous pentamidine, trimethoprim-sulfamethoxazole (Bactrim), trimetrexate glucuronate (NeuTrexin), dapsone, clindamycin, or atovaquone.

According to the Joint Commission’s Core Measures (2010), the first antibiotic dose should be administered within 6 to 8 hours of presentation whenever the admission diagnosis is community-acquired pneumonia. The timeliness of this therapy is related to decreased mortality rates. Supplemental oxygen is provided as needed. Some patients require mechanical ventilation.

Complementary and Alternative Therapies

Treatment for Pneumonia

Barberry root bark is used against bacteria, fungi, and viruses as well as other organisms, (Clin-eguide, 2005) and is an alternative treatment for pneumonia. It has antimicrobial action against both gram-positive and gram-negative bacteria. It should not be used during pregnancy as it can cause spontaneous abortion.

Think Critically

Can you identify five signs or symptoms found on assessment that might correlate with a diagnosis of pneumonia?

Nursing Management

The nursing care plan for a patient with pneumonia should include interventions to:

• Promote oxygenation

• Control elevated temperature

• Maintain nutritional and fluid intake

• Provide adequate rest

• Monitor vital signs and respiratory status

• Relieve pain and discomfort

• Provide good oral hygiene

• Prevent irritation of the lungs by smoke and other irritants

• Avoid secondary bacterial infections

Clinical Cues

The first signs of decreasing oxygenation may be restlessness or confusion. The patient may want to sit upright to allow for better chest excursion. Respiratory rate will increase and later there will be flaring of the nares, then retraction of respiratory muscles if the condition worsens. Cyanosis is a very late sign.

The patient should deep breathe and cough 5 to 10 times each hour while awake. It is important that the nurse assess for signs of increasing impairment of gas exchange. Fluid intake, unless contraindicated, should be increased to 2500 to 3000 mL/day. Because abdominal distention, nausea, and vomiting also may accompany pneumonia, nursing interventions to deal with these problems may be indicated. Other problems include altered states of consciousness (delirium and confusion) or the development of such complications as empyema (see later) and congestive heart failure. For the young adult, convalescence with rest should extend for at least a week after acute symptoms subside. The older adult needs several weeks to do usual activities without undue fatigue.

Elder Care Points

The elderly are more at risk for influenza and pneumonia because of a less efficient immune system, decreased action of cilia, and decreased elasticity and muscle tone.

• Confusion often is the most obvious sign of atypical pneumonia in the elderly.

• It may take 6 to 12 weeks after a bout of pneumonia for an elderly patient to be able to resume normal activities without undue fatigue.

• The very elderly patient may never quite regain the former level of wellness after a serious episode of pneumonia.

• Teach the elderly to seek medical attention quickly if symptoms of pneumonia occur.

Empyema

Empyema occurs when the fluid within the pleural cavity becomes infected and the exudate becomes thick and purulent. The organisms causing the infection may be staphylococci or streptococci. One or more chest tubes are inserted and a closed drainage system is established to remove excess fluid from the pleural cavity. A specimen of the fluid is sent for a culture and sensitivity, which determines the choice of antibiotic therapy.

Fungal Infections

The most common fungal lung infections are coccidioidomycosis and histoplasmosis. Coccidioidomycosis occurs primarily in the western United States and exposure occurs during desert recreational activities or when working in occupations that require digging in the earth. Typically, there are no symptoms or mild respiratory symptoms, but 40% will have cough, fever, pleuritic chest pain, myalgias, and arthralgias. Sometimes a flat red rash with dark red papules occurs. Histoplasmosis occurs in central and eastern portions of North America. The fungus lives in moist soil such as that in which mushrooms grow, on the floors of chicken houses and bat caves, and in bird droppings. Clinical signs are fever, fatigue, cough, dyspnea, and weight loss over 1 to 2 months.

The other fungal infections, such as blastomycosis, cryptococcosis, aspergillosis, and candidiasis, are seen mostly in immunocompromised people or those with cystic fibrosis. Pneumocystis carinii is now considered a fungus, renamed Pneumocystis jiroveci. It is found only in immunocompromised patients and is highly lethal (see Chapter 12). Fungal infections are diagnosed by history, signs and symptoms, and positive skin test reaction to the fungus. Treatment is IV amphotericin B for up to 12 weeks.