72 | 6 top tips to help you nurse patients with lung disease confidently

PodcastRespiratoryEmergency + Critical Care
Written By Laura Jones

Whether you’re managing a patient with aspiration pneumonia, pulmonary oedema or trauma causing haemorrhage and bruising, patients with lung disease can decompensate quickly and need intensive nursing care.

 

Knowing what to look out for and the nursing considerations these patients need is vital - and that’s exactly what we’re discussing in this episode.

We’ll be breaking down the different pulmonary diseases we see, the impact they have on our patients, and how we can manage them successfully as nurses and technicians.

Plus, I’m sharing six of my all-time top tips to help you care for these patients confidently (whilst using a load of nursing skills).

So if you’ve ever felt unsure about pulmonary pathophysiology or felt like you could do more to help your respiratory patients, this episode is for you.

But first, we need to understand how the lungs should work.

When your patient is hypoxaemic (they have a low oxygen saturation or SpO2), this is usually due to one of two things.

Either they can’t get enough air IN to their lungs (ie, they have a problem with their upper airways or lower airways, meaning oxygen-rich air can’t reach the alveoli),

Or they can’t get enough oxygen OUT of their lungs and into the bloodstream - meaning there’s a problem with the alveoli.

Getting that oxygen OUT of the lungs is the problem with pulmonary disease.

The lower airways branch out into smaller and smaller bronchioles, until each ends in a terminal bronchus with an attached alveolar air sac. 

It’s inside these air sacs that gaseous exchange takes place.

Each alveolus is surrounded by alveolar capillaries. Since both the capillary and alveolar walls are one-cell thick, gases (oxygen and carbon dioxide) can readily diffuse between the two.

These gases move down a concentration gradient - ie, from an area with a high concentration to an area with a lower concentration. Oxygen diffuses out of the oxygen-rich air in the alveoli and into the alveolar capillaries, where it binds to haemoglobin and is transported to cells and tissues.

Carbon dioxide diffuses out of the capillaries into the alveoli for elimination.

But our pulmonary diseases interfere with this process.

There are many different pulmonary diseases, but they have one thing in common - they impair gaseous exchange.

The alveoli can fill with fluid, collapse, or become damaged. And when this happens, oxygen can’t diffuse into the blood, and the patient becomes hypoxaemic.

Understanding this helps explain why so many pulmonary diseases look similar clinically, even if the underlying cause is different.

Speaking of those pulmonary diseases, which ones do we see, and why?

There are lots of different diseases that interfere with gaseous exchange, including:

  • Aspiration pneumonia

  • Other forms of pneumonia (including bacterial, viral and fungal infection)

  • Pulmonary haemorrhage

  • Pulmonary contusions (bruising)

  • Pulmonary fibrosis

  • Smoke inhalation

  • Pulmonary oedema

  • Acute respiratory distress syndrome (ARDS)

Let’s look at each of them in more detail to understand better how they work, their impact on our patients, and how we can treat and care for them as nurses and technicians.

First, there’s aspiration pneumonia.

Aspiration pneumonia is one of the most common causes of pulmonary disease in practice. It occurs when oropharyngeal or gastric contents are inhaled into the lungs, usually following vomiting or regurgitation..

Common risk factors include:

  • Megaesophagus

  • Any other causes of vomiting or regurgitation

  • Laryngeal paralysis

  • Brachycephalic airway syndrome

  • Anaesthetic-associated regurgitation (during anaesthesia or recovery)

The aspirated content irritates the lung tissue, causes inflammation, and often introduces bacteria. Common species include E. coli, Klebsiella, Pasteurella, and Staphylococcus spp.

But it’s not just aspiration pneumonia.

Though less common, patients can also present with pneumonia due to other causes. These include viral infections, bacterial infections, and (less commonly) fungal infections.

Viral infections are commonly seen in younger, unvaccinated dogs due to species like distemper, adenovirus and parainfluenza virus. They are highly contagious and often associated with secondary bacterial infections.

Fungal pneumonia is usually seen in specific regions, such as blastomycosis in the US.

All of these infections will cause lung irritation and inflammation, impairing gaseous exchange and causing hypoxaemia.

Next up, we’ve got pulmonary haemorrhage.

As the name suggests, patients with pulmonary haemorrhage bleed into their alveoli, impairing gaseous exchange.

Pulmonary haemorrhage occurs for many reasons, including trauma, coagulopathies (such as anticoagulant rodenticide toxicity), infectious diseases (like lungworm) and neoplasia. 

Similar to pulmonary haemorrhage, we also see hypoxaemia due to pulmonary contusions.

Contusions are usually seen after blunt force thoracic trauma, like road traffic accidents (RTAs). The traumatic impact damages the alveolar-capillary membrane, leading to interstitial and alveolar bleeding without external wounds.

Pulmonary contusions are often delayed-onset; patients have worsening clinical signs around 12-24 hours after the traumatic event, rather than showing severe hypoxaemia or respiratory distress immediately afterwards. If immediate signs are seen, it is usually due to other respiratory disorders, such as a traumatic pneumothorax, though patients can develop pulmonary contusions on top!

And then there’s pulmonary fibrosis.

Pulmonary fibrosis is a chronic, irreversible interstitial lung disease where the walls of the alveoli become progressively thickened and scarred, usually over months to years. 

It’s common in terrier breeds, particularly Westies (fun fact: PF is nicknamed ‘Westie lung’ - which tells you everything you need to know about how common it is in these patients!)

Though these patients generally present with less severe signs, they can have significantly impaired lung function, particularly in the later stages of their disease.

There are a few other pulmonary diseases you need to know about as a vet nurse.

Namely, two: smoke inhalation and non-cardiogenic pulmonary oedema (NCPE).

Smoke inhalation damages the lungs in several ways.

The heat causes airway burns and thermal damage, and the toxic gases and fumes from the inhaled smoke also injure the lungs, causing severe irritation, inflammation and oedema.

And lastly, there’s non-cardiogenic pulmonary oedema (which is very different to heart failure!)

NCPE often occurs due to seizures, electrocution, upper airway obstruction and near-drowning.

These cause the alveolar capillaries to ‘leak’ fluid into the alveoli. This fluid, in turn, impairs gaseous exchange, causing hypoxaemia.

Ok, those are the different pulmonary diseases we see - but what about the clinical signs they cause? 

Whilst the specific clinical signs will vary depending on the underlying cause, most patients will present with similar clinical signs. These include:

  • Acute onset of respiratory distress

  • Tachypnoea

  • Dyspnoea

  • Orthopnoea (where patients adjust their body position to ease ventilation and can appear ‘air-hungry’)

  • Increased respiratory effort

  • Lethargy

  • Exercise intolerance

  • Coughing

  • Harsh lung sounds on auscultation

  • Crackles on auscultation

  • Anorexia

  • Cyanotic mucous membranes (in severe hypoxaemia)

  • Collapse

Other signs these patients can present with include:

  • Pyrexia (in case of infection)

  • Facial burns (in case of smoke inhalation)

  • Signs of bleeding elsewhere (in case of coagulopathy)

  • Nasal discharge

Point-of-care ultrasound of the lungs often reveals areas of consolidation and multiple B-lines (vertical lines which spread from the bottom to the top of the ultrasound field like rockets).

So those are the clinical signs we see - but what do we actually do?

Well, the priority, like any other respiratory emergency, is to stabilise our patient. These patients often present in respiratory distress with severe hypoxaemia, and our role as nurses and technicians is to triage and stabilise them promptly. 

Any diagnostics should wait until the patient’s oxygen saturation has improved, their stress levels have reduced, and they can tolerate handling, imaging, and sedation (where appropriate) without significant deterioration.

Common diagnostics performed in pulmonary disease include:

  • Thoracic radiographs (or CT if available) to identify evidence of pneumonia, contusions, or oedema.

  • Point-of-care ultrasound to identify B-lines, consolidation, or pleural effusion.

  • Bloods, including biochemistry, haematology, inflammatory markers and other specific tests as needed (eg, coagulation times or lungworm testing for patients with pulmonary haemorrhage)

  • Bronchoscopy to visualise the airways

  • BAL (bronchoalveolar lavage - either blindly or via the bronchoscope) or TTW (transtracheal wash) for bacterial culture, cytology and infectious disease testing

  • Pulse oximetry and/or arterial blood gas to assess oxygenation (+/- ventilation in the case of blood gas analysis).

These will help us administer appropriate treatment for the underlying disease process, while also continuing supportive care and monitoring.

Speaking of that treatment and nursing care…

There’s a lot to think about when managing these patients. Our priorities are to provide appropriate oxygen therapy and reverse hypoxaemia, keep the patient calm and comfortable to reduce oxygen demand, and treat their specific disease.

Common medications used to treat different pulmonary diseases include:

  • Antibiotics where needed, guided by culture and sensitivity results

  • Steroids, especially in inflammatory or immune-mediated disease

  • Diuretics in pulmonary oedema (but only where appropriate!)

  • Nebulisation and coupage in pneumonia, to mobilise secretions

But the mainstay of treatment? Oxygen therapy.

If your patient is hypoxaemic, that medication list will only get you so far. We must support their oxygenation, normalise their SpO2 and prevent respiratory fatigue. 

The longer a patient remains hypoxaemic, the more work they’ll put into getting air into their lungs. And the more work they put in, the more those respiratory muscles will tire, ultimately resulting in respiratory failure if we don’t intervene.

Along with oxygen therapy, we need to prioritise supportive care.

Nursing care makes all the difference to these patients. Areas to prioritise include fluid balance (since these patients often have increased losses and reduced fluid intake), respiratory physiotherapy and recumbency care, intensive monitoring, and nutritional support.

Top tips for nursing the pulmonary patient:

Here are my 6 top tips for confident respiratory nursing. We’ve discussed the different diseases we see, how they impact our patients, and the common treatments we use - but we all know that the NURSING is where the real magic happens.

So, when you’re caring for these often critical patients:

  • Prioritise a hands-off approach (where possible), since keeping the patient calm and rested will conserve oxygen

  • Think about HOW you’re delivering that oxygen - it’s not a one-size-fits-all approach, and the lower our patients’ SpO2, the more effective their oxygen delivery needs to be

  • Monitor trends in your patient’s vitals, not just the numbers. Look at their respiratory rate, pattern, effort, and SpO2 changes over time, not just in the moment.

  • Nebulisation and mobilisation are your best friends; getting these patients moving when you can will help clear those airway secretions.

  • Don’t ‘just’ look at the breathing - our trauma patients might be hypoxaemic, but they’ll also be in a lot of pain, so prioritise their analgesia too!

  • Know what to look out for and when to intervene - these patients can deteriorate fast, and we need to look for those early warning signs and advocate for changes to their treatment where required.

So there you have it! My guide to the common pulmonary diseases we see, and how to successfully care for them as a vet nurse. 

Yes, these cases are often complex. Yes, these patients need intensive monitoring and a whole heap of nursing care. But they’re also really rewarding and make great use of our skills.

Did you enjoy this episode? If so, I’d love to hear what you think. Take a screenshot and tag me on Instagram (@vetinternalmedicinenursing) so I can give you a shout-out and share it with a colleague who’d find it helpful!

Thanks for learning with me this week, and I’ll see you next time!


References and Further Reading

Laura Jones
Next

71 | The step-by-step guide to managing lower airway disease in dogs as a veterinary nurse