25. Restrictive (Inflammatory) Lung Diseases and Congestive Heart Failure/Pulmonary Edema




The authors would like to acknowledge David A. Miller for his contributions that remain unchanged from the first edition.




PNEUMONIA




I. Definition of pneumonia


A. Acute febrile inflammatory disorder of the lung(s), associated with cough and exertional dyspnea


B. Infiltrate is present on chest x-ray; the appearance of the infiltrate may lag behind the appearance of symptoms by 24 to 48 hours, justifying a repeat chest x-ray at that time.


C. Leukocytosis may be present.




IV. Evaluation for possible pneumonia


A. Historical information


B. Physical examination


1. Tachypnea


2. Tachycardia


3. Fever


4. Discomfort


5. Rales (or “crackles”) on auscultation over the affected area(s)


C. Chest x-ray, in a search for new pulmonary infiltrates


D. Laboratory studies


1. CBC, including differential WBC count


2. Blood cultures


3. Gram’s stain and culture of sputum


4. Arterial blood gases and/or pulse oximetry



VI. Prevention of pneumonia


A. Vaccination against influenza: Fluvax


1. Repeated annually


2. Some revaccinate within a season in the following circumstances:

If the patient


a. Is immunocompromised


b. Has severe underlying chronic obstructive pulmonary disease or heart disease


B. Vaccination against S. pneumoniae: Pneumovax


1. Repeated every 7 to 10 years or as recommended by the Centers for Disease Control and Prevention


2. Covers only the 23 most virulent strains of S. pneumoniae


TUBERCULOSIS (TB)




I. Etiology: Mycobacterium tuberculosis


II. Incidence


A. The rates of new infection by M. tuberculosis are increasing, especially among the homeless and among those living in crowded conditions in larger metropolitan areas.


B. Alarmingly, the incidence of multidrug-resistant TB (defined as resistant to isoniazid and to rifampin) also appears to be rising, especially along the East and West Coasts of the U.S.


C. This rise has coincided with increased numbers of patients with HIV and AIDS.


III. Clinical findings


A. Symptoms


1. Most patients are asymptomatic


2. Fever


3. Cough, generally productive of purulent sputum that may contain blood


4. Weight loss


5. Night sweats that may require changing of bed linen


B. Physical examination findings


1. Body temperature elevation


2. Cachexia may be noted.


3. Rales over the affected areas: apical posttussive rales for apical disease


C. Laboratory/Diagnostic findings


1. Normal complete CBC


2. Low serum cortisol level if disseminated disease to the adrenal glands has destroyed the adrenal cortices


3. Sputum


a. Acid-fast smears are often positive, but therapy may have to be started empirically if other findings are suggestive of TB in the absence of positive smears.


b. Cultures for M. tuberculosis are usually positive within 6 weeks.


4. TB skin testing (intradermal purified protein derivative [PPD])


a. 0.1 ml PPD injected intradermally; read 48 hours later


b. Interpretation based on measurement of the largest diameter of the indurated area (not including flat but erythematous area):


i. Less than 5 mm: negative test


ii. 5 mm or greater: positive test in an HIV-infected patient or others immunocompromised


iii. 10 mm or greater: positive test in health care workers, HIV-negative injection drug users, residents of nursing homes/homeless shelters, etc.


iv. 15 mm or greater: positive test in the general population


D. Chest x-ray


1. Infiltrate


a. Especially present in the upper lobes of the lungs, or in the superior segments of the lower lobes


b. Can be present in any portion of the lungs


2. Cavity within the lungs


IV. Treatment


A. Patient isolation during initial evaluation and treatment, according to Occupational Safety and Health Administration (OSHA) standards, is mandatory.


B. Suspected disease, or smear-positive disease, pending the return of sputum cultures


C. Prophylaxis


1. Consider for the following patients:


a. Asymptomatic, with a positive PPD and a normal chest x-ray


b. Exposed to active TB who have a negative PPD


c. Undergoing immunosuppressive therapy for other reasons


d. Who have HIV infection


2. Treatment


a. INH, 300 mg PO daily, although controversy exists as to whether 6 months or up to 1 year of therapy should be given


b. Pyridoxine, 50 mg PO daily, may be also chosen during INH therapy.

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Mar 3, 2017 | Posted by in NURSING | Comments Off on 25. Restrictive (Inflammatory) Lung Diseases and Congestive Heart Failure/Pulmonary Edema

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