A nurse is caring for a client who has a respiratory infection. which of the following techniques

Although much of the care that respiratory patients receive at a primary, secondary and tertiary level is provided by nonspecialised nurses, patients in many European countries are seen and managed by respiratory nurse specialists. Respiratory nurses are engaged in the holistic care of patients with lung diseases, with the aim of maintaining the highest nursing standards, while working in collaboration with other members of a healthcare team. Specialist nurses work in various settings (inpatient and outpatient hospital departments and patients’ homes) and, in addition to providing patient care, they are often involved in preventive programmes (e.g. smoking cessation and patient education).

Role

Respiratory nurses are sometimes involved in the development, clinical application and monitoring of new diagnostic and therapeutic procedures. They participate in research that aims to improve health and prevent disease, and collaborate in investigations involving patients with lung disease. Respiratory nurses are involved in almost all care programmes for patients with respiratory diseases including pulmonary hypertension, asthma, COPD, tuberculosis, transplantation, respiratory oncology, sleep disorders, and cystic fibrosis; they play a crucial and specific role in the care, education and self-management of patients within such programmes. In each care programme, they also have specific tasks: they monitor and treat patients, and ensure that patients adhere to the agreed therapy. As care moves away from the classical ‘clinic’ setting, respiratory nurses are also becoming active in the primary care of patients with COPD and asthma. This shift should be accompanied by proper education in the management of respiratory patients.

Respiratory nurses have an important role in patient education, the enhancement of patient self-management and the management of care. For more than 20 years, the British Thoracic Society (BTS) has recommended that respiratory nurse specialists should be attached to all respiratory medicine departments to act as a link between the hospital and the community. Several studies have examined the role of respiratory nurse specialists. It has been shown that they are effective in guiding self-management in asthma patients, and in coordinating an integrated care pathway focusing on identification, early intervention and management in COPD, including supervision of early hospital discharge and long-term care. An Australian study has shown the beneficial effects of domiciliary respiratory nurse intervention in the care of COPD patients: although mortality was unchanged, involvement of an outreach respiratory nurse as part of a shared-care approach resulted in improved health-related quality of life.

A programme in Kilkenny, Ireland has identified that comprehensive care plans for older people with chronic respiratory diseases need to include training for respiratory nurse specialists in hospitals and the community to address the following areas of patient care:

• use of long-term oxygen
• accurate diagnosis
• appropriate use of medication
• monitoring of treatment efficacy
• community/hospital rehabilitation programmes, where appropriate
• smoking cessation
• multidisciplinary assessment and intervention
• recognition of early warning signs of an exacerbation with rapid access to appropriate services

Similar programmes exist in Spain and are predominantly led by respiratory nurses. A recent meta-analysis has highlighted the effectiveness of nurse-led programmes and has particularly shown the effects on health-related quality of life.

In patients with complex therapeutic schemes (e.g. patients suffering from pulmonary hypertension, those on long-term oxygen therapy and those receiving noninvasive mechanical ventilation), specifically trained nurses are key to ensuring quality care. More and more tele-health applications are used and overseen by respiratory nurses, allowing for remote monitoring and the adjustment of therapy.

An increasingly important element of the specialist respiratory nurse’s role is to act as a clinical study nurse and coordinator. As respiratory nurses excel in providing patients with information at patients’ level of understanding, and are trained in patient interview skills and the techniques relevant to respiratory research, they often run clinical trial units and help engage patients in clinical trials.

Respiratory nursing websites (see Respiratory Nursing Websites below) describe the respiratory nurse’s role as promoting pulmonary health in individuals, families and communities, and caring for those with pulmonary dysfunction throughout their lifespan. Respiratory nursing care is preventive, acute or critical, and rehabilitative. A respiratory nurse may be employed as a staff nurse, clinical nurse specialist, nurse practitioner, nurse manager, supervisor, coordinator, director, executive, nurse educator, or research nurse; they are employed by hospitals, extended care centres, private companies, health departments, office practices and clinics. The Standards of Nursing Care for Adult Patients with Pulmonary Dysfunction developed by the Nursing Assembly of the American Thoracic Society (ATS) in 1989 offers a detailed guide to respiratory nursing clinical care.

Respiratory Nursing Websites:

Nurse.com - www.nurse.com
Respiratory Nursing Society www.respiratorynursingsociety.org 
Association of Respiratory Nurse Specialists www.arns.co.uk  
European Respiratory Society Nurses Group http://www.ersnet.org/assemblies/allied-respiratory-professionals/item/146-nurses.html
American Thoracic Society Nursing Assembly www.thoracic.org/assemblies/nur/index.php

Training

Professional societies at a regional level have a key role to play in training and education. Much of the nursing care that respiratory patients receive is provided by professionally trained nurses. In many disease areas, however, there  is a need for specifically trained nurses with a Masters-level degree or similar. Postgraduate education may allow respiratory nurses the opportunity to train to become leaders of care programmes. Within the ERS, the Nurses Group  (part of the Allied Respiratory Professionals Assembly) ensures such training at a European level. Similarly, the ATS has a dedicated Nursing Assembly. Its mission statement summarises the aim of respiratory nurses as follows: 1) to prevent disease and disability in respiratory, critical care and sleep-related conditions; 2) to improve the management of symptoms resulting from these conditions; and 3) to enhance end-of-life and palliative care. The Assembly has also composed a formal list of research priorities for respiratory nurses.

See the entire Allied respiratory professionals Chapter

Upper respiratory tract infections can be defined as self-limited irritation and swelling of the upper airways with associated cough and no signs of pneumonia, in a patient with no other condition that would account for their symptoms, or with no history of chronic obstructive pulmonary disease, emphysema, or chronic bronchitis. Upper respiratory tract infections involve the nose, sinuses, pharynx, larynx, and large airways. This activity examines when an upper respiratory tract infections should be considered on differential diagnosis and how to properly evaluate it. This activity highlights the role of the interprofessional team in caring for patients with this condition.

Objectives:

• Describe the pathophysiology of upper respiratory tract infections.

• Review the history and physical of a patient with an upper respiratory tract infection.

• Outline the management options for upper respiratory tract infections.

• Explain interprofessional team strategies for improving care coordination and outcomes in patients with upper respiratory tract infections.

A variety of viruses and bacteria can cause upper respiratory tract infections. These cause a variety of patient diseases including acute bronchitis, the common cold, influenza, and respiratory distress syndromes. Defining most of these patient diseases is difficult because the presentations connected with upper respiratory tract infections (URIs) commonly overlap and their causes are similar. Upper respiratory tract infections can be defined as self-limited irritation and swelling of the upper airways with associated cough with no proof of pneumonia, lacking a separate condition to account for the patient symptoms, or with no history of COPD/emphysema/chronic bronchitis. [1]  Upper respiratory tract infections involve the nose, sinuses, pharynx, larynx, and the large airways.

Common cold continues to be a large burden on society, economically and socially. The most common virus is rhinovirus. Other viruses include the influenza virus, adenovirus, enterovirus, and respiratory syncytial virus. Bacteria may cause roughly 15% of sudden onset pharyngitis presentations. The most common is S. pyogenes, a Group A streptococcus.

Risk factors for a URTI

• Close contact with children: both daycares and schools increase the risk fo URI

• Medical disorder: People with asthma and allergic rhinitis are more likely to develop URI

• Smoking is a common risk factor for URI

• Immunocompromised individuals including those with cystic fibrosis, HIV, use of corticosteroids, transplantation, and post-splenectomy are at high risk for URI

• Anatomical anomalies including facial dysmorphic changes or nasal polyposis also increase the risk of URI

Across the country, URIs are one of the top three diagnoses in the outpatient setting.   Estimated annual costs for viral URI, not related to influenza, exceeds $22 billion. [2] Upper respiratory tract infections account for an estimated 10 million outpatient appointments a year. Relief of symptoms is the main reason for outpatient visits amongst adults during the initial couple weeks of sickness, and a majority of these appointments result with physicians needless writing of antibiotic prescriptions. Adults obtain a common cold around two to three times yearly whereas pediatrics can have up to eight cases yearly.[3],[4],[5]  Fall months see a peak in incidence of common cold caused by the rhinovirus. Upper respiratory tract infections are accountable for greater than 20 million missed days of school and greater than 20 million days of work lost, thus generating a large economic burden. [6]

A URTI usually involves direct invasion of the upper airway mucosa by the organism. The organism is usually acquired by inhalation of infected droplets. Barriers that prevent the organism from attaching to the mucosa include 1) the hair lining that traps pathogens, 2) the mucus which also traps organisms 3) the angle between the pharynx and nose which prevents particles from falling into the airways and 4) ciliated cells in the lower airways that transport the pathogens back to the pharynx.

The adenoids and tonsils also contain immunological cells that attack the pathogens.

Influenza

The incubation period for influenza is 1 to 4 days, and the time interval between symptom onset is estimated to be 3 to 4 days. Viral shedding can occur 1 day before the onset of symptoms. It is believed that influenza can be transferred among humans by direct contact, indirect contact, droplets, or aerosolization. Short distances (<1 meter) are generally required for contact and droplet transmission to occur between the source person and the susceptible individual. Airborne transmission may occur over longer distances (>1 m). Most evidence-based data suggest that direct contact and droplet transfer are the predominant modes of transmission for influenza. [7]

Common Cold

The pathogens are responsible for causing the common cold include rhinovirus, adenovirus, parainfluenza virus, respiratory syncytial virus, enterovirus, and coronavirus. The rhinovirus, a species of the Enterovirus genus of the Picornaviridae family, is the most common cause of the common cold and causes up to 80% of all respiratory infections during peak seasons.[8] Dozens of rhinovirus serotypes and frequent antigenic changes among them make identification, characterization, and eradication complex. After deposition in the anterior nasal mucosa, rhinovirus replication and infection are thought to begin upon mucociliary transport to the posterior nasopharynx and adenoids. As soon as 10 to 12 hours after inoculation, symptoms may begin. The mean duration of symptoms is 7 to 10 days, but symptoms can persist for as long as 3 weeks. Nasal mucosal infection and the host's subsequent inflammatory response cause vasodilation and increased vascular permeability. These events result in nasal obstruction and rhinorrhea whereas cholinergic stimulation prompts mucus production and sneezing.

Acute upper respiratory tract infections include rhinitis, pharyngitis, tonsillitis, and laryngitis. Symptoms of URTIs commonly include:

• Cough

• Sore throat

• Runny nose

• Nasal congestion

• Headache

• Low-grade fever

• Facial pressure

• Sneezing

• Malaise

• Myalgias

The onset of symptoms usually begins one to three days after exposure and lasts 7–10 days, and can persist up to 3 weeks.

The presence of classical features for rhinovirus infection, coupled with the absence of signs of bacterial infection or serious respiratory illness, is sufficient to make the diagnosis of the common cold. The common cold is a clinical diagnosis, and diagnostic testing is not necessary. When testing for influenza, obtain specimens as close to symptom onset as possible. Nasal aspirates and swabs are the best specimens to obtain when testing infants and young children. For older children and adults, swabs and aspirates from the nasopharynx are preferred. Rapid strep swabs can be used to rule out bacterial pharyngitis, which could help decrease number of antibiotics being prescribed for these infections.

The goal of treatment for the common cold is symptom relief. Decongestants and combination antihistamine/decongestant medications can limit cough, congestion, and other symptoms in adults.[9] Avoid cough preparations in children.[10] H1-receptor antagonists may offer a modest reduction of rhinorrhea and sneezing during the first 2 days of a cold in adults. [3] First-generation antihistamines are sedating, so advise the patient about caution during their use. Topical and oral nasal decongestants (i.e., topical oxymetazoline, oral pseudoephedrine) have moderate benefit in adults and adolescents in reducing nasal airway resistance.[10], [3] Evidence-based data does not support the use of antibiotics in the treatment of the common cold because they do not improve symptoms or shorten the course of illness.[10], [3] There is also a lack of convincing evidence supporting the use of dextromethorphan for acute cough.

According to a Cochrane Review,[11] vitamin C used as daily prophylaxis at doses of =0.2 grams or more had a "modest but consistent effect" on the duration and severity of common cold symptoms (8% and 13% decreases in duration for adults and children, respectively). When taken therapeutically after the onset of symptoms, however, high-dose vitamin C has not shown clear benefit in trials.[11]

Early antiviral treatment for influenza infection shortens the duration of influenza symptoms, decreases the length of hospital stays, and reduces the risk of complications.[ Recommendations for the treatment of influenza are updated frequently by the Centers for Disease Control and Prevention based on epidemiologic data and antiviral resistance patterns. Give antiviral therapy for influenza within 48 hours of symptom onset (or earlier), and do not delay treatment for laboratory confirmation if a rapid test is not available. Antiviral treatment can provide benefit even after 48 hours in pregnant and other high-risk patients.[12]

Vaccination is the most effective method of preventing influenza illness. Antiviral chemoprophylaxis is also helpful in preventing influenza (70% to 90% effective) and should be considered as an adjunct to vaccination in certain scenarios or when vaccination is unavailable or not possible. Generally, antiviral chemoprophylaxis is used during periods of influenza activity for (1) high-risk persons who cannot receive vaccination (due to contraindications) or in whom recent vaccination does not, or is not expected to, afford a sufficient immune response; (2) controlling outbreaks among high-risk persons in institutional settings; and (3) high-risk persons with influenza exposures. [13]

Differential Diagnosis

• Streptococcal Pharyngitis/Tonsillitis

URI are common during the winter season and for the most part, are benign, but they can seriously affect the quality of life for a few weeks. A few individuals may develop pneumonia, meningitis, sepsis, and bronchitis. Each year, there are isolated cases of death reported from a URI. Time off work and school is very common. In addition, patients spend billions of dollars on worthless remedies. There is little evidence that any treatment actually shortens the duration of a viral URI. Even the vaccine only works in 40-60% of individuals, at best.

Complications of upper respiratory tract infections are relatively rare, except with influenza. Complications of influenza infection include primary influenza viral pneumonia; secondary bacterial pneumonia; sinusitis; otitis media; coinfection with bacterial agents; and exacerbation of preexisting medical conditions, particularly asthma and chronic obstructive pulmonary disease. Pneumonia is one of the most common complications of influenza illness in children and contributes significantly to morbidity and mortality.

Upper respiratory tract infections are one of the most common illnesses that healthcare workers will encounter in an outpatient setting. The infection may vary from the common cold to a life-threatening illness like acute epiglottitis. Because of the diverse causes and presentation, upper respiratory tract infections are best managed by an interprofessional team.

The key is to avoid over-prescribing of antibiotics but at the same time not missing a life-threatening infection. Nurse practitioners who see these patients should freely communicate with an infectious disease expert if there is any doubt about the severity of the infection. The pharmacist should educate the patient on URI and to refrain from overusing unproven products.

Similarly, the emergency department physician should not readily discharge patients home with antibiotics for the common cold. Overall, upper respiratory tract infections lead to very high disability for short periods. Absenteeism from work and schools is common; in addition, the symptoms can be annoying and extreme fatigue is the norm. Patients should be encouraged to drink ample fluids, rest, discontinue smoking and remain compliant with the prescribed medications.[14]

Nursing can monitor the patient's condition and symptoms, counsel on medication compliance, and report any concerns to the clinicians managing the case. INterprofessinoal cooperation is key to good outcomes. [Level 5]

Finally, clinicians should urge patients to get vaccinated before the flu season. While the vaccine may not decrease the duration of the infection, the symptoms are much less severe.

The outcomes in most patients are good, particularly with the interprofessional team approach. [Level 5]

Review Questions

1.

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Arroll B. Common cold. BMJ Clin Evid. 2008 Jun 09;2008 [PMC free article: PMC2907967] [PubMed: 19450292]

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Irwin RS, Baumann MH, Bolser DC, Boulet LP, Braman SS, Brightling CE, Brown KK, Canning BJ, Chang AB, Dicpinigaitis PV, Eccles R, Glomb WB, Goldstein LB, Graham LM, Hargreave FE, Kvale PA, Lewis SZ, McCool FD, McCrory DC, Prakash UBS, Pratter MR, Rosen MJ, Schulman E, Shannon JJ, Hammond CS, Tarlo SM. Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines. Chest. 2006 Jan;129(1 Suppl):1S-23S. [PMC free article: PMC3345522] [PubMed: 16428686]

Fashner J, Ericson K, Werner S. Treatment of the common cold in children and adults. Am Fam Physician. 2012 Jul 15;86(2):153-9. [PubMed: 22962927]

Douglas RM, Hemilä H, Chalker E, Treacy B. Vitamin C for preventing and treating the common cold. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD000980. [PubMed: 17636648]

Siston AM, Rasmussen SA, Honein MA, Fry AM, Seib K, Callaghan WM, Louie J, Doyle TJ, Crockett M, Lynfield R, Moore Z, Wiedeman C, Anand M, Tabony L, Nielsen CF, Waller K, Page S, Thompson JM, Avery C, Springs CB, Jones T, Williams JL, Newsome K, Finelli L, Jamieson DJ., Pandemic H1N1 Influenza in Pregnancy Working Group. Pandemic 2009 influenza A(H1N1) virus illness among pregnant women in the United States. JAMA. 2010 Apr 21;303(15):1517-25. [PMC free article: PMC5823273] [PubMed: 20407061]

Harper SA, Bradley JS, Englund JA, File TM, Gravenstein S, Hayden FG, McGeer AJ, Neuzil KM, Pavia AT, Tapper ML, Uyeki TM, Zimmerman RK., Expert Panel of the Infectious Diseases Society of America. Seasonal influenza in adults and children--diagnosis, treatment, chemoprophylaxis, and institutional outbreak management: clinical practice guidelines of the Infectious Diseases Society of America. Clin Infect Dis. 2009 Apr 15;48(8):1003-32. [PMC free article: PMC7107965] [PubMed: 19281331]

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