Learning Objectives
By the end of this section, you will be able to:
- Discuss the effects of smoking, vaping, and environmental triggers of the respiratory system
- Apply nursing concepts and plan associated nursing care for the patient who smokes, vapes, or has environmental triggers of respiratory illness
- Evaluate the efficacy of nursing care for the patient who smokes, vapes, or has environmental triggers of respiratory illness
Worldwide, cigarette smoking causes over seven million deaths every year. New tobacco products, e-cigarettes, became available around 2007 and rapidly gained popularity. Today, millions of Americans, including adolescents, use e-cigarettes (“vape”). Despite known health risks, this profitable industry continues to use marketing and advertising to promote cigarettes and vaping. Due to the novelty of e-cigarettes, long-term data to illustrate the consequences and trajectory of use is not available.
Pathophysiology of Smoking and Vaping
The pathophysiology of cigarette smoking affects virtually every body system. Tobacco smoke contains about sixty known carcinogens. Research suggests that these carcinogens damage DNA, causing mutations that lead to tumor formation. When tobacco smoke is inhaled, it causes an inflammatory state in the lungs and increases the number of free radicals in the body. Increased oxidative stress leads to problems with dilation and constriction of blood vessels, increased blood clot risk, and increased inflammation. This can cause serious coronary artery disease (Adams & Morris, 2022). Smoking is a primary risk factor for developing COPD. Lung damage results in elevated CO2, low oxygen levels, and vasoconstriction.
In vaping, the e-cigarette heats up a solution, which vaporizes and can be inhaled. This solution can contain nicotine, tetrahydrocannabinol (THC), butane hash oils, and cannabidiol, as well as other additives. The vaporization process turns the solution into ultrafine particles, allowing volatile organic compounds and heavy metals to be inhaled. Some of the additives decompose into dangerous compounds (e.g., formaldehyde). Similar to cigarette smoking, these compounds have been linked to oxidative stress, inflammation, emphysema, and increased cardiovascular risk (Perkins, 2020).
Clinical Manifestations of Chronic Effects from Smoking and Vaping
Smoking and vaping both carry a risk of causing severe health problems for patients. The danger may feel abstract to patients because noticeable problems may not occur for months or years.
Assessment and Diagnostics
Chronic smoking can cause many clinical symptoms and conditions. Some patients may smoke heavily for years before encountering symptoms. Chronic cough, dyspnea, hypoxia, and development of COPD are common. Smoking is linked with many other lung conditions (e.g., pulmonary fibrosis) and can exacerbate asthmatic symptoms. Many diagnostic tests are used to evaluate respiratory problems related to smoking. Imaging can include chest x-ray, CT scan, and ultrasound. The lungs can be directly visualized and biopsied by using bronchoscopy. Pulmonary function testing can be used to evaluate lung function.
Patients who use e-cigarettes can develop EVALI (e-cigarette or vaping use-associated lung injury). This can cause chest pain, bloody sputum, fever, cough, headache, muscle aches, fatigue, and shortness of breath. EVALI can result in life-threatening complications, including hemorrhage, pneumonia, acute lung injury, and pneumothorax. In addition, they can develop pleural effusion, a serious consequence that impacts breathing due to fluid accumulated in the pleural space and acute respiratory distress syndrome (ARDS), a potentially fatal complication. As a result of lung injury, fluid builds up in the lungs, oxygen levels drop, and scarring can occur. Vital sign changes include increased respiratory rate and decreased oxygen level. Because these symptoms are nonspecific and can occur with many diseases, EVALI is considered a diagnosis of exclusion. Diagnostic tests will include chest x-ray, CT scan, bronchoscopy, and influenza screening (Perkins, 2020).
Smoking is linked to approximately 90 percent of lung cancer cases and is the most significant risk factor. The U.S. Preventive Services Task Force currently recommends that certain smokers undergo periodic low-dose CT screening to evaluate for lung cancer. When lung cancer is caught at an early stage, treatment is more likely to be effective. Annual CT screening is recommended for adults between the ages of fifty to eighty, with a twenty pack-year smoking history, who smoke currently, or quit sometime in the last fifteen years (U.S. Preventive Services Task Force, 2021).
Nursing Care of the Patient Who Smokes and/or Vapes
In both the near- and long-term, smoking and vaping can have serious consequences for patients. Nursing care aims to stabilize the immediate situation and provide resources to mitigate future complications. Cessation strategies and support are central aspects of nursing care.
Recognizing Cues and Analyzing Cues
Accurately understanding a patient’s smoking history is important. The nurse should ask how many packs or cartridges per day the patient consumes, and how many years they have smoked. The nurse evaluates subjective and objective data, including patient reports of cough, dyspnea, and pain. Physical assessment evaluates for adventitious lung sounds and changes that can occur with chronic smoking-related lung disease, such as a barrel-chested appearance. Patient position can provide important information about work of breathing. Many patients struggling to breathe are unable to tolerate lying flat and instinctively assume an upright, tripod position. Vital signs are assessed with a focus on respiratory rate and oxygen saturation. Educate the patient about fire safety concerns related to cigarette or e-cigarette smoking. Traditional cigarettes have a fire risk related to the open flame; e-cigarettes also have a fire risk related to the battery.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
In patients who smoke cigarettes or vape, respiratory status is a high priority. Depending on the complication, the nurse may need to monitor vital signs, prepare a patient for imaging, or administer medications. Medications may be oral, intravenous, or inhaled. Many patients will require supplemental oxygen. Patient education around fire safety, especially for patients who use supplemental oxygen, is an important nursing action. Smoke detectors and fire extinguishers should be readily available. Smoking in the same room as oxygen is potentially life-threatening.
At a minimum, patients need to stay at least six feet from an open flame (candle, fireplace, or stove) (MedlinePlus, 2022).
Supporting patients in efforts to quit smoking is a crucial nursing action. Structured frameworks exist that can guide clinicians as they undertake this complex task. The U.S. Preventive Services Task Force recommends the 5A’s approach (Table 11.11).
| Intervention | Technique |
|---|---|
| Ask | Implement an officewide system that ensures that, for every patient at every clinic visit, tobacco-use status is queried and documented. Repeated assessment is not necessary in the case of the adult who has never used tobacco, or has not used tobacco for many years, and for whom this information is clearly documented in the medical record. |
| Advise | Strongly urge all tobacco users to quit in a clear, strong, personalized manner. |
| Advice should be: | |
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| Assess | Determine the patient’s willingness to quit smoking within the next thirty days: |
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| Assist | Provide aid for the patient to quit. These actions are summarized in the accompanying table. |
| Arrange | Schedule follow-up contact, either in person or by telephone. Follow-up contact should occur soon after the quit date, preferably during the first week. A second follow-up contact is recommended within the first month. Schedule further follow-up contacts as indicated. |
| Congratulate success during each follow-up. If tobacco use has occurred, review circumstances and elicit recommitment to total abstinence. Remind the patient that a lapse can be used as a learning experience. Identify problems already encountered and anticipate challenges in the immediate future. Assess pharmacotherapy use and problems. Consider use or referral to more intensive treatment. |
Cessation-related interventions may include nicotine replacement therapy, other medications, and support groups/mental health counseling. To maximize the likelihood of success, implementation strategies must be comprehensive (Table 11.12).
| Action | Strategies for Implementation |
|---|---|
| Help the patient with a quit plan | Set a quit date. Ideally, the quit date should be within two weeks. |
| Tell family, friends, and coworkers about quitting and request understanding and support. | |
| Anticipate challenges to planned quit attempt, particularly during the critical first few weeks. These include nicotine withdrawal symptoms. | |
| Remove tobacco products from the environment. Prior to quitting, avoid smoking in places where they spend a lot of time (e.g., work, home, car). | |
| Provide practical counseling (problem-solving/training) | Abstinence: Total abstinence is essential. “Not even a single puff after the quit date.” |
| Past quit experience: Review past quit attempts, including identification of what helped during the quit attempt and what factors contributed to relapse. | |
| Anticipate triggers or challenges in upcoming attempt: Discuss challenges/triggers and how patient will successfully overcome them. | |
| Advise patient to remove all tobacco from home, car, and work environment. | |
| Alcohol: Because alcohol can cause relapse, the patient should consider limiting/abstaining from alcohol while quitting. | |
| Other smokers in the household: Quitting is more difficult when there is another smoker in the household. Patients should encourage housemates to quit with them or not smoke in their presence. | |
| Provide intra-treatment social support | Provide a supportive clinical environment while encouraging the patient in their quit attempt. “My office staff and I are available to assist you.” |
| Help the patient obtain extra-treatment social support | Help the patient develop social support for their quit attempt in their environments outside of treatment. “Ask your spouse/partner, friends, and coworkers to support you in your quit attempt.” |
| Recommend the use of approved pharmacotherapy, except in special circumstances | Recommend the use of pharmacotherapies found to be effective. Explain how these medications increase smoking cessation success and reduce withdrawal symptoms. |
| Provide supplementary materials | Sources: Federal agencies, nonprofit agencies, or local/state health departments. Offer a free telephone quitline (in the United States, 1-800-QUIT-NOW or 1-800-784-8669 can be used). |
| Type: Culturally/racially/educationally/age appropriate for the patient | |
| Location: Readily available at every clinician’s workstation |
Evaluation of Nursing Care for the Patient Who Smokes and/or Vapes
When providing nursing care for the patient who smokes and/or vapes, the nurse uses subjective and objective data to determine next steps. Nursing care may impact physiologic status, medication regimens, and cessation. When evaluating the patient with complications from smoking or vaping, the nurse asks if their respiratory status has stabilized or improved. The nurse can evaluate lung sounds, perceived dyspnea, oxygen requirement, and medication regimen. Regarding smoking and vaping cessation, the nurse can assess any changes in the patient cigarette/e-cigarette usage along with the patient’s symptoms and adherence to a medication regimen.
Medical Therapies and Related Care
Medical therapies related to cigarette smoking and vaping focus primarily on treating conditions that have developed and supporting patients to quit. E-cigarettes are not recommended as a cigarette smoking cessation strategy. Nicotine replacement therapy and other medications can help patients stop smoking. For patients with complications related to cigarette smoking, medical treatment will often involve inhalers, bronchodilators, and corticosteroids. Patients may also need to use supplemental oxygen to maintain their respiratory status.
In patients with EVALI, hospital admission may be required, and supplemental oxygen is commonly needed. Antibiotics are commonly utilized; corticosteroids are used in severe cases (Perkins, 2020). When serious complications develop (e.g., diffuse alveolar hemorrhage), emergent treatment is necessary. Bronchoscopy can be used to visualize and stop bleeding. Treatment options for bleeding available via bronchoscopy include topical vasoconstrictors (e.g., epinephrine), tamponade, and lavage with iced saline (Ingbar & Dincer, 2023).
Collaborative care for patients who smoke and vape includes many disciplines. Nursing, medicine, pharmacy, and respiratory therapy will work together on the plan of care that includes medications, oxygen therapy, imaging, and procedures. Social workers and mental health counselors can be important sources of support for patients and families dealing with smoking-related consequences and challenges with quitting.
Pathophysiology, Risk Factors, and Clinical Manifestations of Environmental Triggers on Respiratory Illness
Work-related asthma is a common respiratory illness related to environmental triggers. Exposure to allergens, high temperatures, humidity extremes, and irritants can cause airway irritation and constriction. Inhaling dust, fumes, gases, and vapors can cause COPD and worsen existing cases. Asbestos exposure can lead to lung irritation as well as cancer. Asbestosis occurs when asbestos is inhaled, and mesothelioma is the asbestos-linked cancer that can arise in the lining of the lungs. Moreover, black lung disease, or pneumoconiosis, is a pulmonary disease that leads to lung scarring as a result of inhaled coal dusts. Histoplasmosis is a fungal infection caused by inhaling spores from soil (American Lung Association, n.d.).
Due to a variety of respiratory illnesses caused by environmental triggers, the manifestations can vary. Common symptoms do include shortness of breath, productive cough, wheezing, chest pain, and a history of known exposure to an environmental trigger. Patients may be asymptomatic for many years before damage becomes apparent. Diagnosis is made using history and physical, pulmonary function tests, x-ray, tissue biopsy, and CT scan (American Lung Association, n.d.).
Nursing Care of the Patient with Respiratory Illness from Environmental Triggers
Respiratory illness from environmental triggers can be serious, progressive, and debilitating. Nursing care centers on exposure identification, physiologic stabilization, and emotional well-being.
Recognizing Cues and Analyzing Cues
When evaluating patients with a suspected or confirmed respiratory illness related to an environmental trigger, potential exposure to substances and smoking history are both considered. Patients should be questioned about their occupations (e.g., miners, farmers, construction workers, factory workers) to help determine if environmental hazards are present. The nurse considers the possible triggering substance along with the duration and frequency of exposure. It is crucial to understand what, if any, personal protective equipment the patient had access to at the time of potential exposure. Some environmentally triggered respiratory illnesses have a rapid onset; others are delayed for years. Subjective data will include the patient’s description of symptoms, including time of onset. The nurse evaluates objective data, including lung sounds, shortness of breath, and cough. Vital signs are evaluated with a focus on respiratory rate and oxygen saturation.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
High-priority findings include acute respiratory distress and hypoxia. The nurse may need to monitor vital signs, prepare a patient for imaging or pulmonary function tests, or administer medications. Many patients with environmentally triggered respiratory illnesses will require supplemental oxygen. Because most of these illnesses are incurable, patient and caregiver stressors are often present, and the nurse prioritizes emotional well-being and coping skills through facilitating access to resources like support groups, financial assistance, and mental health counseling. Smoking cessation education is a high-priority action.
Evaluation of Nursing Care with Respiratory Illness from Environmental Triggers
Because most environmentally triggered respiratory illnesses are permanent, a cure is not usually a possible outcome. For most patients, the goal is to stabilize or improve their respiratory status, at least temporarily. The nurse can evaluate lung sounds, perceived dyspnea, ability to perform activities of daily living, oxygen requirements, and medication regimen to determine the patient’s respiratory status.
Medical Therapies and Related Care
Unfortunately, there is no cure for most environmentally triggered lung diseases, although some treatments can delay disease progression. Histoplasmosis is one environmentally triggered lung disease that can be cured; antifungal medication is administered for three months to a year. Key treatment strategies focus on preventing future exposure and smoking cessation. Oxygen therapy will often be necessary with most diseases. Bronchodilators can often improve symptoms by opening up airways. Pulmonary rehabilitation therapy can help some patients improve quality of life and activity tolerance. Surgery, including lung transplantation, may be necessary in some cases.
Link to Learning
New medications are becoming available that can slow the progression of some lung diseases. Nintedanib (Ofev) is used to treat idiopathic pulmonary fibrosis as well as lung fibrosis that occurs with scleroderma and progressive fibrosing interstitial lung disease. Review this patient education information from the American College of Rheumatology to learn more.