Chapter 26: Concepts of Care for Patients With Noninfectious Upper Respiratory Problems

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Welcome to the Deep Dive.

Today we're jumping into non -infectious upper respiratory problems.

Our mission, get you fluent, fast, in the critical concepts, straight from the source material.

We're aiming for the highest priority stuff here.

Exactly.

And if there's one core concept that really ties all this together, it's got to be gas exchange.

Think about it.

The nose, pharynx, larynx, trachea, they're the only way oxygen gets into the body.

So job number one is keeping that pathway open, patented.

Makes sense.

Keep the air moving.

Always.

And closely related is tissue integrity, especially when we start talking about trauma and surgical stuff later on.

Okay.

So we'll definitely hit obstructive sleep apnea, OSA, as the big example for chronic issues.

But first things first, the immediate lifesavers.

Let's tackle upper airway obstruction head on.

Right.

Upper airway obstruction is pretty much what it says on the tin.

Air flow gets blocked somewhere in those upper structures.

And because gas exchange stops,

like instantly when that happens, spotting it early is absolutely crucial.

Okay.

So what causes it?

I'm thinking big things like major trauma.

How's you?

Or maybe swelling.

Yeah, you definitely see it with severe trauma.

Or like you said, swelling tongue edema from an allergic reaction, maybe angioedema or laryngeal edema from smoke inhalation.

Those are common culprits.

But is there something less dramatic, something that might, you know, sneak up on us?

Actually, yes.

And it's kind of surprising.

One of the most dangerous causes can be something seemingly simple.

Inspecated secretions.

Inspecated, meaning really thick, hardened mucus.

Exactly.

Think thickly crusted gunk in the mouth or back of the nose.

If someone has say altered mental status or they're dehydrated, maybe can't cough well.

And if oral hygiene isn't great, those secretions can literally harden like cement and completely blast the airway.

Wow.

Okay.

So basic mouth care suddenly becomes potentially life -saving.

That feels like a major safety point.

It absolutely is.

It's an action alert level priority.

Assessing oral care needs daily, especially in high -risk folks, and making sure everyone, including assistive personnel, does it right.

That's key to preventing this.

So how do we spot an obstruction happening?

What are the signs?

Well, if it's just a partial block, you might see things like sweating, fast heart rate, maybe anxiety, higher blood pressure, kind of general distress signals.

But when it gets severe, the signs are unmistakable.

Hypoxia, restlessness, you'll see them pulling with muscles in their neck and chest, sternal retractions.

And you might hear stridor, that really harsh high -pitched noise when they breathe in.

Patients often feel this sense of doom, like they just can't get air.

Okay.

So we're watching for those signs.

How do we monitor pulse ox?

Pulse oximetry, definitely.

And increasingly,

end tidal CO2 monitoring at CO2.

That gives you a real -time look at ventilation.

And interventions.

What can we do right away?

Simple stuff first.

If it looks like the tongue's just fallen back, maybe a head tilting lift or jaw thrust.

If it's secretions, suctioning, obviously.

If you know it's a foreign object,

abdominal thrusts, what people used to call the Heimlich maneuver.

Right.

Now, there's a specific rule about abdominal thrusts on someone who's unconscious, isn't there?

Yes.

Super important safety point.

If someone collapses and you didn't see them choke and they have no pulse, you start chest compressions, CPR first.

You only do abdominal thrusts on an unconscious person if you know there's an obstruction and they still have a pulse.

Because statistically, cardiac arrest is more likely in that collapsed scenario.

Okay.

Clear distinction.

But what if none of that works quickly?

What are the emergency moves?

If you can't clear it fast, you need an advanced airway, STAT.

Sometimes enter tracheal intubation, especially if you expect swelling.

But for a median access, it might be a cricothyroidotomy, basically a quick surgical opening through the membrane in the neck.

That buys time until a formal tracheomy can be done for a more stable airway.

All right.

Let's shift gears from those acute emergencies to something more chronic.

Obstructive sleep apnea, OSA.

You call it our gas exchange exemplar.

What's actually going on physiologically here?

Okay.

So OSA.

The definition is pretty specific.

Breathing stops or it gets really shallow.

That's hypopnea during sleep.

It has to last at least 10 seconds and happen at least five times an hour.

What happens is when the person sleeps, the muscles in their head and neck relax.

Too much relaxation sometimes.

And the soft palate or the tongue or both just collapse backward and block the airway.

So they stop breathing, CO2 climbs.

Yep.

CO2 goes up, oxygen drops.

The brain senses this, panics a little, and jolts the person just awake enough to take a breath, often with a gas or a snort.

Ah, so that clears the obstruction momentarily.

Right.

Then they fall back asleep, relax again, obstruct again, and the cycle just repeats over and over.

Okay, I get the cycle.

But why is this such a big deal beyond just feeling tired?

What are the long -term risks you mentioned?

Oh, the long -term effects are serious, really serious.

You've got the chronic daytime sleepiness, obviously, but the repeated oxygen drops and stress on the body.

That leads to high blood pressure, often hypertension that doesn't respond well to meds, increased risk of stroke,

cognitive problems like memory and concentration issues.

And it puts a huge strain on the heart and lungs, increasing the risk for major cardiovascular and pulmonary disease down the line.

It's systemic.

Okay, that definitely puts it in perspective.

So when we're assessing someone, what clues point towards OSA?

Often it's the bed partner who notices first.

Heavy snoring is classic.

But the patient might report just feeling exhausted all the time, maybe falling asleep during the day, even while working or driving.

Morning headaches are common too, irritability.

Some people even report frequent nightmares.

And an interesting link, the chest and abdominal movements trying to overcome the obstruction can actually trigger or worsen nighttime GERD, that acid reflex.

GERD2.

Okay, so if we suspect OSA based on these signs, maybe use a screening tool like Stop Beeping.

How do we get a definitive diagnosis?

Yeah, screening tools are a good start.

Epworth's sleepiness scale is another one.

But the gold standard, the definitive test, is polysemography.

That's the overnight sleep study, right?

What exactly are they monitoring?

Everything.

Brain waves with an ECG, heart rhythm with ECG, muscle activity, eye movements, breathing effort, airflow, oxygen levels,

the works.

They're watching you sleep, basically, and recording precisely how many times you stop breathing or have shallow breathing, how low your oxygen gets, and what sleep stages you're actually reaching.

Comprehensive.

Okay, so let's say the sleep study confirms OSA.

What are the treatment options?

I can make a huge difference.

Sometimes just changing sleep position like avoiding sleeping on your back helps too.

There are also oral appliances, kind of like mouth guards, that reposition the jaw to keep the airway open.

But the main treatment seems to be CPAP, right?

Absolutely.

Continuous Positive Airway Pressure.

CPAP is the cornerstone for most people.

It's a machine that delivers pressurized air through a mask and that constant pressure acts like a splint to physically hold the airway open so it can't collapse during sleep.

Have the machines gotten better?

I feel like people used to complain about them being bulky and loud.

Oh, definitely.

They're much quieter now, smaller, often have built -in humidifiers, which makes it more comfortable, and the masks have improved.

You can get nasal pillows that are much less intrusive.

All that helps with adherence, which is the real key.

You need to use it consistently.

The recommendation is usually at least six hours a night to really get the health benefits and reduce those long -term risks we talked about.

Six hours minimum.

Okay, what if someone just can't tolerate CPAP or their OSA is really severe?

Are there surgical options?

Yes, surgery is an option then.

It's not usually the first line, though.

Simpler procedures might just be removing tonsils or the uvula, if they're part of the problem.

The more common major surgery used to be called UPPP, but now it's often a modified uvulopalatopharyngoplasty, or mod -UPPP.

The goal now is less about just removing tissue and more about repositioning and reinforcing the throat to open up space.

Interesting.

Any newer approaches?

Yeah, technology is moving forward here, too.

There are minimally invasive options now, like implantable hypoglossal nerve stimulators.

Like a pacemaker.

Kind of.

It senses when you breathe in during sleep and sends a little electrical pulse to the nerve that controls the tongue, moving it forward just enough to keep the airway clear.

Pretty neat.

That is clever, and I assume the absolute last resort is...

Tracheostomy.

Creating that surgical airway in the neck bypasses the upper airway obstruction completely.

But yeah, that's reserved for the most severe refractory cases.

Okay, let's shift focus again.

We've covered obstruction and OSA.

Now let's hit some other common non -infectious issues, starting with something everyone's experienced.

Epistaxis, nosebleeds.

Right, very common.

The nose has a ton of blood vessels close to the surface.

Trauma is a big cause, obviously.

But also dry air, high blood pressure, sometimes blood clotting disorders, even just picking your nose.

So for a typical anterior bleed, the kind that drips out the front, what's the best first aid?

Keep it simple.

Sit upright, lean forward.

You don't want the blood going down your throat.

Pinch the soft part of your nose firmly, just below the bone, for a good 10 minutes straight.

No peeking.

Ice or a cool compress on the bridge of the nose can help, too.

And once it stops, try really hard not to blow your nose for about 24 hours.

Let that clot stabilize.

Okay, lean forward, pinch for 10 minutes.

Got it.

But the source material really flags posterior nosebleeds as emergencies.

Why the difference?

Location, location, location.

Posterior bleeds are further back, higher up in the nasal cavity.

They're often from bigger vessels, so the bleeding can be much heavier and harder to control with just pressure.

And because the blood tends to run down the throat, there's a serious risk of airway compromise or aspirating blood.

Plus, you can lose a significant amount of blood quickly.

So how are those managed?

They usually require packing either special posterior packs or sometimes inflatable balloons or tubes placed deep in the nasal cavity.

This is uncomfortable and carries risks.

Patients with posterior packing need close monitoring, usually in the hospital, because the packing itself can sometimes interfere with breathing or shift, causing respiratory distress or hypoxemia.

It's a much bigger deal.

Okay, moving from bleeds to bricks, nasal and facial trauma.

If someone comes in after a facial impact, what's priority number one?

Airway, airway, airway.

Always gas exchange is paramount.

Check for obstruction, difficulty breathing, listen for stridor.

And then assessing the injury itself.

What are you looking for besides the obvious bruising or deformity?

You want to gently feel for crepitus, that crackling sensation under the skin, which means air has escaped into the tissues.

Check alignment.

And critically, look for any clear drainage from the nostrils.

Clear drainage.

You're thinking CSF leak.

Exactly.

Clear watery drainage could be cerebrospinal fluid, meaning the fracture extends up to the base of the skull.

That's serious.

How can you quickly check if that clear fluid is CSF?

Two bedside tests.

One, test it for glucose using a urine dipstick.

CSF has glucose, mucus generally doesn't.

Two, let a drop fall into some gauze or filter paper.

If it's CSF, you'll often see a yellowish halo ring form around the central spot of blood as the fluids separate.

Either side needs immediate attention.

Good tips.

Now, if someone needs surgery for a broken nose, a rhinoplasty, they often come out with packing inside the nose, right?

Which means they have to breathe through their mouth.

Correct.

And this leads to a really important action alert for post -op care.

Frequent swallowing.

If your patient with nasal packing starts swallowing repeatedly, that's a huge red flag for posterior bleeding.

The blood is trickling down the back of their throat and they're swallowing it.

You need to assess that immediately.

Okay.

Frequent swallowing equals possible posterior bleed.

Noted.

What about more severe facial fractures?

I know there's a classification system.

Yes.

The LaForte classification for mid -face fractures.

LaForte the third is lower down, Sousa's is more pyramid -shaped, and LaForte the third is the most severe.

It's basically a craniofacial disjunction where the whole mid -face is detached from the skull base.

These often involve airway compromise and CSF leaks.

That sounds incredibly serious.

Sometimes they need their jaw wired shut, right?

Intermaxillary fixation or IMF.

Yes.

For certain jaw fractures, wiring the jaws together, IMF, immobilizes the bone for healing, usually for about six to ten weeks.

They're on a liquid diet the whole time.

Six to ten weeks wired shut.

Oh, okay.

That immediately brings up a huge safety concern.

What if they need to vomit?

This is absolutely critical.

It's a critical safety alert.

The patient must be taught how to cut the wires themselves, and they must keep wire cutters with them at all times, two hundred four seven.

Why?

If they vomit and can't open their mouth, they will aspirate.

It's an immediate airway emergency.

Cutting the wires is their lifeline.

They need to know how and when to do it without hesitation.

Wow.

Wire cutters are non -negotiable.

Okay, one more trauma type.

Laryngeal trauma.

Injury to the voice box area.

Usually from a crushing blow, a fracture of the cartilage, sometimes from prolonged or traumatic intubation.

What are the signs there?

Difficulty breathing is key.

Horseness or even aphonia, the complete inability to make sound.

You might also see or feel subcutaneous emphysema, that crackly air under the skin in the neck area.

And the priority.

Airway again.

Maintaining a patent airway is the absolute highest priority.

It says constantly for any worsening respiratory difficulty, stridor, nasal flaring, anxiety, dropping O2 sats.

Be ready for emergency intubation or tracheotomy because swelling can happen fast and close off the airway.

Alright, let's move into our final section.

Head and neck cancer.

What type of cancer are we usually talking about here?

Overwhelmingly, it's squamous cell carcinoma.

It typically starts as a small area irritation in the lining the mucosa of the mouth, throat, or larynx.

Often, it first appears as a white patch that's leukoplakia or sometimes a red velvety patch called erythroplakia.

These can be precancerous or early cancer.

It tends to spread first to the lymph nodes in the neck.

And what are the biggest risk factors driving this?

The two giants are tobacco smoking, chewing, all forms, and heavy alcohol use.

And using both together.

That multiplies the risk significantly.

Are there others?

Yes.

Infection with certain strains of HPV, human papillomavirus, is increasingly recognized as a major cause, particularly for throat cancers.

Interestingly though, HPV positive cancers often respond better to treatment and have a better prognosis.

Other factors include things like voice abuse, poor oral hygiene over the long term, and chronic GERD irritating the throat.

Okay.

So what warning signs should make someone think, I need to get this checked out?

The source material often has a table for this.

Yeah.

Table 26 .1 usually lays these out.

The key of persistence.

Things like hoarseness or a change in voice quality that lasts for, say, three or four weeks without a clear reason, especially concerning for laryngeal cancer.

Also, a sore in the mouth that doesn't heal,

a lump in the neck or throat,

difficulty or pain with swallowing that doesn't go away, persistent ear pain, especially just on one side, or any unexplained bleeding in the mouth.

Don't ignore those persistent symptoms.

Got it.

Persistence is key.

Let's talk treatment.

Radiation is common, right?

What are the side effects we need to manage?

Radiation is a mainstay, either alone or with chemo.

Side effects can be tough.

Hoarseness and dysphagia difficulty swallowing are common during and after treatment.

Skin reactions in the treatment area are also frequent, so patients need to protect that skin from sun, heat, and cold.

But the really significant long -term one is often xerostomia.

Permanent severe dry mouth.

Salivary glands get damaged.

This isn't just uncomfortable.

It dramatically increases the risk of cavities, makes eating difficult, and impacts quality of life.

Managing xerostomia with saliva substitutes, meticulous oral care, and hydration is crucial.

Lifelong.

Okay.

And chemo or biotherapy?

Often used in combination with radiation that's chemoradiation.

Or sometimes targeted therapies like cetuximab are used, which target specific molecules on the cancer cells.

And then there's surgery,

which can range quite a bit.

Right.

From minimally invasive laser surgery for small early lesions, all the way up to major resections, like a total laryngectomy.

Let's focus on total laryngectomy.

That's removal of the entire larynx, the voice box.

What's the major outcome of that surgery?

The biggest thing to understand is that it results in a permanent separation of the airway from the mouth and esophagus.

The person no longer breathes through their nose or mouth.

They breathe through a permanent opening in their neck called the laryngectomy stoma.

A permanent neck stoma.

Okay.

Post -op care must be intense.

What are the top priorities?

Number one, without a doubt, is airway maintenance.

Keeping that new stoma clear and patented.

Monitoring for any signs of obstruction from mucus plugs or swelling.

Also watching closely for hemorrhage, wound breakdown.

And there's one really critical, potentially lethal complication you have to be hyper aware of.

Which is?

Carotid artery leak or rupture.

Their carotid artery runs right near the surgical site in the neck.

Sometimes, rarely, the vessel wall can weaken post -op.

Okay.

That sounds terrifying.

What's the protocol if you suspect a leak, maybe see a little ooze near the suture line?

This is a critical rescue situation.

The guidance is crystal clear.

If you suspect a leak, do not touch or put pressure on the area.

Call the rapid response team or surgeon immediately.

Applying pressure can actually cause a weakened artery to rupture fully.

Okay.

Do not touch a suspected leak.

Call for help.

But what if it does rupture?

Massive bleeding.

If it ruptures, it's an immediate life -threatening hemorrhage.

In that case, you must apply direct, constant, firm manual pressure right on the OR immediately.

It's a dire emergency.

Understood.

Heavy stuff.

What about nutrition after a total laryngectomy?

Can they aspirate food into the stoma?

Good question.

Because the airway is now completely separate from the esophagus, aspiration of food or liquid into the lungs cannot happen through the stoma.

That's one positive outcome.

However, swallowing is often difficult initially, and these patients are at very high risk for malnutrition.

So they almost always have an NG tube, or more commonly a long -term gastrostomy tube, like a PEG tube, for nutritional support until they can swallow safely and adequately.

And pain.

Pain can be significant, especially with the rich nerve supply in that area.

Scheduled opioid analgesics, often parenterally at first, are usually needed for effective control.

Losing your voice box means losing your natural voice.

How do patients communicate?

That's a huge adjustment, obviously.

Initially, it's writing, using picture boards, maybe a tablet.

Then they work with speech therapy to learn new methods.

Options include using an artificial larynx or electrolarynx, that device held against the neck.

Some learn esophageal speech, using swallowed air to vibrate the esophagus.

Or they might be candidates for a tracheosophageal puncture, TEP, where a small valve is placed between the trachea and esophagus, allowing air to pass into the esophagus to create voice when the stoma is covered.

Seems like a long rehab process.

It is.

Peer support is invaluable here.

Connecting the patient with someone else who has successfully gone through a laryngectomy can make a huge difference.

Now, quickly, what if someone had only a partial laryngectomy?

They still have some voice box left right.

But are they at risk for aspiration, then?

Yes, absolutely.

With a partial laryngectomy, the airway and food passages are still connected, so aspiration is a definite risk.

They need to relearn how to swallow safely.

And there's a specific technique for that.

Yes, the supraglottic method of swallowing.

It's a sequence they have practiced.

Basically, clear your throat, take a deep breath, hold your breath while bearing down slightly, swallow twice, clear your throat again, then swallow twice more.

It's designed to protect the airway during the swallow.

Okay, that sounds like something requiring lots of practice.

Finally, what about home care for someone with a permanent laryngectomy stoma?

What do they need to know?

A lot of it is about protecting that airway.

No swimming, obviously.

Use a special shield when to keep water out.

Wear a stoma cover or loose clothing over it, not tight collars.

Hygiene is key.

Clean around the stoma daily with mild soap and water.

And keeping the air they breathe humidified is important to prevent thick secretions using saline drops in the stoma, a home humidifier.

And safety.

Crucial.

They need to wear a MedicAlert bracelet or necklace and carry an emergency ID card explaining they are a neck breather and how to provide emergency ventilation via the stoma, not the mouth or nose.

That makes sense.

Any psychosocial tips?

One thing to prepare them for is that strong emotions, laughing, crying, will now produce mucus or air directly from the stoma unexpectedly.

Learning to just calmly cover the stoma with a handkerchief is part of adapting.

Hashtag, tag, outro.

So wrapping this all up, if we look back across everything, acute obstruction from, say, those inspecated secretions, chronic issues like trauma, the cancer, the constant thread is airway gas exchange.

Absolutely.

It all comes back to maintaining that patent airway and recognizing the risks, whether it's teaching about wire cutters for IMF or knowing exactly what to do and important one not to do for a potential carotid leak.

Those safety specifics are critical.

They really are a powerful reminder of the nursing role.

And maybe a final thought for you, our listener.

Think about the person who's had a total larynectomy.

Beyond the physical changes, consider the profound psychosocial impact of losing your natural voice, the altered body image.

It really highlights why recovery needs that whole interprofessional team supporting them long after the surgery is done.

That's all the time we have for this deep dive.

Thanks for joining us.

We hope this detailed walkthrough helps solidify these crucial concepts for you.