Ch21

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Oct 30, 2023

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Copyright ©2020 F.A. Davis Company Chapter 21 Restrictive and Obstructive Pulmonary Disorders
Copyright ©2020 F.A. Davis Company Basic Concepts Classification of lung disease based on • PFT: Pulmonary function test (spirometry) Obstructive • Increased resistance to airflow • Emphysema, chronic bronchitis, bronchiectasis, asthma Restrictive • Reduced expansion of lung tissue, decreased total lung capacity • Pulmonary fibrosis, pneumoconiosis, thoracic cage deformities
Copyright ©2020 F.A. Davis Company Lung Disease Smoking a primary risk factor in some forms of lung disease Secondhand smoke also plays a role Occupational and environmental exposures to harmful substances
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Copyright ©2020 F.A. Davis Company Bronchodilation and Bronchoconstriction Smooth muscle in bronchi and bronchioles • Control diameter of airway and air flow Innervated by autonomic nervous system • Sympathetic: bronchiole dilation ‒ Beta-2 adrenergic receptors • Parasympathetic: bronchiole constriction Chemical mediator of bronchoconstriction • Leukotrienes: secreted by WBC ’ s • Histamine: released by mast cells
Copyright ©2020 F.A. Davis Company Compliance Flexibility of lungs Reduced by illness (pneumonia, bronchitis) and inflammation Reduced compliance increases work of breathing
Copyright ©2020 F.A. Davis Company Pleural Membrane Lines chest cavity and envelops lungs Thin film of fluid lubricates membrane layers Pleural space: • Area between membrane linings Negative intrathoracic pressure enables lungs to inflate easily • If air/fluid enter pleural space, lung expansion more difficult Pleural effusion: fluid in pleural space
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Copyright ©2020 F.A. Davis Company Hypoxia and Hypercapnia Hypoxia: lack of oxygen • Hypoxemia ‒ Lack of oxygen in bloodstream Hypercapnia: elevated carbon dioxide levels Hypoxia and hypercapnia may occur together • Lungs can not exchange adequate oxygen or carbon dioxide
Copyright ©2020 F.A. Davis Company Chronic Hypercapnia PaCO 2 greater than 45 mm Hg (normal 35–45 mm Hg) Normal response • Elevated CO 2 stimulates medulla and increased ventilation Chronic hypercapnia • Headache, drowsiness, intellectual impairment
Copyright ©2020 F.A. Davis Company Chronic Hypercapnia (continued) If hypercapnia prolonged, central chemoreceptors become insensitive to CO 2 levels Chronic hypercapnia • Elevated CO 2 no longer serves as primary stimulus for ventilation • Stimulus for breathing shifts to the chemoreceptors in carotids and aorta • Low oxygen drives ventilation (hypoxic drive)
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Copyright ©2020 F.A. Davis Company Chronic Hypoxia Ideal PaO 2 : 90 to 100 mm Hg Mild hypoxemia causes few symptoms • PO 2 levels as low as 70 mm Hg have hemoglobin saturation of almost 90% Dramatic drop in hemoglobin saturation at PO 2 of 60 mm Hg or less • Inadequate oxygen delivery Restlessness, uncoordinated movement, impaired judgment
Copyright ©2020 F.A. Davis Company Chronic Hypoxia (continued) Stimulates increased ventilation Stimulates increased erythropoietin (EPO) • EPO secreted by kidneys • Stimulates the bone marrow to synthesize RBC ’ s Stimulates pulmonary vasoconstriction • Vasoconstriction in areas of lungs with low oxygen • May lead to pulmonary hypertension, which may cause right-side heart failure ( cor pulmonale )
Copyright ©2020 F.A. Davis Company Hypoxia and Erythropoietin
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Copyright ©2020 F.A. Davis Company Pulmonary Assessment Current/past smoking habits Smoking history in pack-years • Number of years smoked multiplied by number of packs smoked per day Example: • 76-year-old patient has smoked two packs per day since age 16 years • 120 pack-year smoking history (2 packs per day x 60 years)
Copyright ©2020 F.A. Davis Company Pulmonary Assessment (continued) Occupational exposure to toxic agents Drug use (marijuana, cocaine) Nonrespiratory disorders • Cardiac disease, HIV, immunosuppression, lupus, sarcoidosis Genetics • Alpha-1 antitrypsin (AAT) deficiency (increased risk for lung disorders)
Copyright ©2020 F.A. Davis Company Pulmonary Signs and Symptoms Auscultation Rate, rhythm, depth of breathing Accessory muscle use Cyanosis • Bluish discoloration Thoracic cage • Normal ‒ Width 2X size of depth of chest • Long-term COPD ‒ Width and depth equal ‒ “Barrel-chest”
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Copyright ©2020 F.A. Davis Company Pulmonary Signs and Symptoms (continued) Adventitious breath sounds Percussion • Dull/hyperresonant Clubbing of fingers • Occurs with chronic hypoxia
Copyright ©2020 F.A. Davis Company Pulmonary Diagnosis Chest x-ray CT scan, MRI V-Q scan ABGs Bronchoscopy PFT ’ s (pulmonary function tests)
Copyright ©2020 F.A. Davis Company Pulmonary Function Tests (PFT ’ s) Total lung capacity (TLC) • Amount of air in lungs after maximal inhalation Functional residual capacity (FRC) • Amount of air remaining in lungs after normal exhalation Residual volume (RV) • Amount of air in lungs after a complete exhalation Tidal volume (TV) • Normal breathing volumes in inhalation and exhalation
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Copyright ©2020 F.A. Davis Company Pulmonary Function Testing
Copyright ©2020 F.A. Davis Company Forced Exhalations Forced vital capacity (FVC) • Maximal amount of air exhaled after maximal inhalation Forced expiratory volume (FEV) • Amount of air exhaled usually within a time interval • FEV 1.0 amount of air exhaled first second • Ratio: FEV1/FVC Forced expiratory flow (FEV25%–75%) • Airflow halfway through an exhale Peak expiratory flow (PEF) • How quickly an individual can exhale
Copyright ©2020 F.A. Davis Company Forced Exhalations (continued)
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Copyright ©2020 F.A. Davis Company Classification of Pulmonary Disorders
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Copyright ©2020 F.A. Davis Company General Pulmonary Treatments Bronchodilators • LABA: Long-acting beta-2 adrenergic agonists • SABA: short-acting beta-2 adrenergic agonists Anti-inflammatory agents • Corticosteroids (IC ’ s: inhaled corticosteroids) • Leukotriene antagonists Rescue medications Maintenance medications
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Copyright ©2020 F.A. Davis Company General Pulmonary Treatments (continued) Nebulizers Lung volume reduction surgery (LVRS) Intubation Mechanical ventilation
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Copyright ©2020 F.A. Davis Company Obstructive Disorders Asthma COPD Bronchiectasis Sleep-disordered breathing
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Copyright ©2020 F.A. Davis Company Asthma Hyperreactive airway disease of bronchioles Reversible airway constriction Each attack leads to inflammatory changes • Bronchial remodeling Different etiologies, multifactorial genetics • Allergies, occupational exposure, viral infections, GERD (especially nocturnal asthma), exercise- induced
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Copyright ©2020 F.A. Davis Company Asthma (continued_1)
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Copyright ©2020 F.A. Davis Company Asthma (continued_2) Bronchoconstriction, bronchial edema, viscous mucus, thickened bronchial basement membrane T cells, IgE ’ s, leukotrienes (bronchiole constriction), histamine (inflammation), eosinophils all play a role
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Copyright ©2020 F.A. Davis Company Symptoms of Asthma Prolonged expiration Wheezing Cough Dyspnea Chest tightness Use of accessory muscles Severity depends on degree of bronchial constriction and reversibility
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Copyright ©2020 F.A. Davis Company Diagnosis of Asthma PFT ’ s: FVC and FEV1 • Diagnose and evaluate the severity of attack During an acute asthma attack • FEV decreases • Diminishes the overall FEV1/FVC ratio Reassess ratio after bronchodilator use • Asthma ‒ Increase of 12% or greater and 200 ml increase in FVC after bronchodilator
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Copyright ©2020 F.A. Davis Company Asthma Classifications Mild intermittent • Symptoms occur fewer than two times a week, attacks are brief • FEV1 greater than 80% of normal during asthma attacks Mild persistent • Symptoms are occurring more than twice a week, but not as often as daily • FEV1 greater than or equal to 80% of normal during asthma attacks
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Copyright ©2020 F.A. Davis Company Asthma Classifications (continued) Moderate persistent • Daily symptoms, quick-relief inhaler daily • Asthma attacks at least 2X per week • FEV1: 60% and 80% of normal, FEV1/FVC ratio reduced by 5% Severe persistent • Symptoms are basically continuous • FEV1 less than 60% of normal • FEV1/FVC ratio reduced by greater than 5%
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Copyright ©2020 F.A. Davis Company Asthma Treatment Stepwise approach Medications • Maintenance: daily ‒ LABA ‒ IC ‒ Anti-leukotriene (if needed) • Rescue : acute attack ‒ SABA Cromolyn sodium • Stabilizes mast cells • Reduce allergic response Bronchial thermoplasty Limit exposure to allergen
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Copyright ©2020 F.A. Davis Company Status Asthmaticus Persistent bronchoconstriction despite attempts to reverse Decreased arterial oxygen and increased carbon dioxide Can be fatal
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Copyright ©2020 F.A. Davis Company Chronic Obstructive Pulmonary Disorder (COPD) Combination of chronic bronchitis, emphysema, and hyperreactive airways • Narrowing of bronchioles, excessive mucus, loss of alveolar recoil, smooth muscle hypertrophy Smoking is major cause Genetic and environmental factors • AAT deficiency ‒ Alpha-1 antitrypsin ‒ Increases risk of pulmonary damage
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Copyright ©2020 F.A. Davis Company Chronic Bronchitis in COPD Hypersecretion of mucus in airways • Patient can not get air into lungs • Cough present for 3 months of year for 2 consecutive years Hypoxia and cyanosis result
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Copyright ©2020 F.A. Davis Company Emphysema in COPD Overdistension of alveoli • Loss of elastic recoil • Patient can’t get air out of lungs Air trapping • High residual volume • High carbon dioxide in lungs
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Copyright ©2020 F.A. Davis Company Alveoli in Chronic Bronchitis and Emphysema
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Copyright ©2020 F.A. Davis Company Comparison Chronic Bronchitis Mucus and edema Cannot get air IN Cyanosis Cough Chronic hypoxia Clubbing of fingers Pulmonary arterial vasoconstriction NICKNAME: BLUE BLOATER Emphysema Air trapping Cannot get air OUT Chronic hypercapnia Prolonged exhalation Barrel-shaped chest Diaphragm pushed downward
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Copyright ©2020 F.A. Davis Company Cor Pulmonale in Severe COPD Decreased oxygenation in lungs leads to pulmonary vasoconstriction Increased workload on RV may lead to right- side heart failure RV failure caused by pulmonary disease called cor pulmonale Signs and symptoms • JVD, ascites, hepatomegaly, ankle edema
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Copyright ©2020 F.A. Davis Company Changes in Breathing Stimulus Due to COPD Normal breathing stimulus: increased CO 2 In severe COPD, CO 2 levels chronically elevated Chemoreceptors and respiratory center become insensitive to high CO 2 • Respiratory drive then comes from peripheral chemoreceptors and O 2 levels (hypoxic drive) • Oxygen titration to keep hypoxic drive • Use caution with agents that depress respiratory drive (tranquilizers, sedatives, and opiates)
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Copyright ©2020 F.A. Davis Company Diagnosis of COPD COPD Assessment Test (CAT) • Patient questionnaire PFT ’ s • FEV1: Significant decrease due to prolonged, slow exhalation • FEV1/FVC ratio less than 70% CBC, chest x-ray, ABG ’ s, ECG
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Copyright ©2020 F.A. Davis Company Treatment of COPD Stepwise approach with medications • SABA ’ s, LABA ’ s, long-acting anticholinergic (anti- muscarinic) agents (LAMA ’ s) • IC ’ s • Leukotriene antagonists Smoking cessation, pulmonary rehabilitation, vaccinations Oxygen therapy: continuous oxygen when PaO 2 less than 55 mm Hg or SaO 2 less than 88%
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Copyright ©2020 F.A. Davis Company Bronchiectasis Uncommon disease Untreated infections lead to chronic inflammation and dilatation of bronchi • Pseudomonas aeruginosa, Haemophilus influenzae, Staphylococcus aureus, adenovirus and influenza, aspergillus Bronchiole wall destroyed and replaced by fibrous tissue
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Copyright ©2020 F.A. Davis Company Bronchiectasis (continued) Bronchioles irreversibly dilated Patients present with persistent cough and purulent sputum, hemoptysis may occur Reduced PFT ’ s Treatment involves treating underlying infection • Mucolytic agents and bronchodilators
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Copyright ©2020 F.A. Davis Company Sleep-Disordered Breathing (SDB) Obstructive sleep apnea (OSA), central sleep apnea (CSA), or combination • Apnea ‒ Reduction in airflow by 90% for at least 10 seconds • OSA ‒ Intermittent collapse of upper airway tissues • CSA ‒ Loss of respiratory drive from brainstem Result in sleep disturbance, daytime sleepiness, hypoxemia
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Copyright ©2020 F.A. Davis Company Obstructive Sleep Apnea (OSA) Symptoms • Loud snoring, choking or gasping during sleep, un restful sleep, and daytime sleepiness Obesity a risk factor Other risks include nasal blockage, airway anatomy OSA worsened by alcohol and sedative- hypnotic medications
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Copyright ©2020 F.A. Davis Company Sleep-Disordered Breathing Diagnosis • Sleep study (polysomnography) Treatment • Behavioral changes • CPAP (continuous positive airway pressure) device ‒ Prevents airway closing • Oral appliance that pulls the tongue forward may help • Surgery to open upper airway structures
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Copyright ©2020 F.A. Davis Company Restrictive Pulmonary Disease Prevent complete ventilation, diminished total lung capacity • Pneumothorax • Pleural effusion • Pulmonary fibrosis • Environmental lung disorders • Immunological disorder: sarcoidosis • Thoracic cage limitations (scoliosis) • Neurological disorders (i.e., MS)
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Copyright ©2020 F.A. Davis Company Pneumothorax Collapsed lung Air in the pleural cavity causes collapse of a large section or whole lobe of lung tissue Forms • Primary spontaneous pneumothorax (PSP) • Secondary spontaneous pneumothorax (SSP) • Traumatic • Tension • Iatrogenic
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Copyright ©2020 F.A. Davis Company Pneumothorax (continued_1)
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Copyright ©2020 F.A. Davis Company Primary Spontaneous Pneumothorax Air in intrapleural space, no preceding trauma or underlying lung disease Most common in tall, young men between the ages of 10 and 30 years old Unclear etiology, but ruptured alveoli are theorized to be the cause
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Copyright ©2020 F.A. Davis Company Secondary Spontaneous Pneumothorax Occurs in a wide variety of lung diseases Underlying pathological process in the lung Air enters the pleural space via ruptured blebs (overly distended and damaged alveoli) Patients with long-term emphysema most at risk
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Copyright ©2020 F.A. Davis Company Traumatic Pneumothorax Often due to penetrating wound of the thoracic cage pleural membrane • Commonly, a thoracic wound causes a rib fracture that punctures the pleural membrane • An opening between the pleural cavity and outside atmosphere created • Air enters pleural cavity, compressing lung tissue
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Copyright ©2020 F.A. Davis Company Pneumothorax (continued_2) Tension Escalating buildup of air within lung compresses the lung, bronchioles, cardiac structures, vena cava Closed, penetrating wound allows air into pleural cavity, but not out Life-threatening as cardiac structures compressed Iatrogenic Complication of medical procedures Often: transthoracic needle aspiration
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Copyright ©2020 F.A. Davis Company Pneumothorax (continued_3) Symptoms • Chest pain, dyspnea, and increased respiratory rate Asymmetry of the chest, as well as intercostal muscle retractions Percussion may reveal hyperresonance Auscultation may reveal a lack of breath sounds on affected side
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Copyright ©2020 F.A. Davis Company Pneumothorax Diagnosis Chest x-ray or CT scan Chest x-ray • Linear shadow of visceral pleura with lack of lung markings peripheral to the shadows • Mediastinal shift toward the contralateral, undamaged lung Pulse oximetry and ABG ’ s may reveal hypoxemia
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Copyright ©2020 F.A. Davis Company Pneumothorax Treatment Chest tube with suction • Pulls the air out of the pleural cavity and allows the collapsed lung to re-expand Tension pneumothorax • Large bore needle inserted in affected side to pull out air Oxygen administration Pleurodesis • Prevents recurrence • Intentional irritation of pleural membrane causes membranes to adhere together • Closes off pleural space
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Copyright ©2020 F.A. Davis Company Pleural Effusion Abnormal collection of fluid in pleural cavity • Compresses lung tissue Fluid accumulates due to heart failure, severe pulmonary infection, or neoplasm • Fluid may be exudate or transudate, purulent, lymph, or sanguineous (bloody) Thoracentesis • Relieve pressure on the lungs and provide fluid for analysis
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Copyright ©2020 F.A. Davis Company Pleuritis Also called pleurisy Inflammation of the pleural membrane
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Copyright ©2020 F.A. Davis Company Pleural Effusion (continued) Signs • Dyspnea, tachypnea • Sharp pleuritic chest pain • Dullness to percussion • Diminished breath sounds on the affected side • Lack of breath sounds over area of effusion
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Copyright ©2020 F.A. Davis Company Environmental Lung Diseases (Pneumoconioses) Result from exposure to specific airborne agents or particulate air pollution Most dangerous • Particles that reach terminal small airways • Macrophages overwhelmed by large quantity of dust or particles Coal worker’s pneumoconiosis, asbestosis, and silicosis
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Copyright ©2020 F.A. Davis Company Pneumoconiosis Coal worker pneumoconiosis: anthracosis • Blackened lung, gray sputum, and wheezes • Can occur with exposure to air pollution Asbestosis • Pulmonary fibrosis • Carcinogen (mesothelioma: tumor specifically associated with asbestos) Silicosis: quartz crystal that if inhaled causes pulmonary fibrosis
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Copyright ©2020 F.A. Davis Company Thoracic Cage Deformity Kyphoscoliosis • Kyphosis ‒ Curve of cervical spine • Scoliosis ‒ Twisting of thoracic vertebral column Noticeable deformity • 1 shoulder or hip higher than the other Orthopedic brace or surgical intervention
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Copyright ©2020 F.A. Davis Company Idiopathic Pulmonary Fibrosis (IPF) Injury of lung tissue by an unidentified agent • Repeated alveoli inflammation causes fibrotic changes (lung tissue stiffens) Dyspnea, tachypnea, crackles, and eventual cyanosis Chest x-ray • “Ground glass” appearance Treatment • Decrease inflammation and fibrotic changes
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Copyright ©2020 F.A. Davis Company Hypersensitivity Pneumonitis Immunologically mediated due to prolonged, intense exposure to inhaled organic dusts Bacterial spores, fungi, or animal proteins Abnormally heightened sensitivity to the antigen causes alveolar inflammation Prolonged exposure can lead to pulmonary fibrosis
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Copyright ©2020 F.A. Davis Company Pulmonary Vascular Disorders Pulmonary edema Pulmonary embolism Pulmonary hypertension
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Copyright ©2020 F.A. Davis Company Pulmonary Edema Most common cause: LV failure (LVF) LVF • LV can not eject blood forward • Blood accumulates in LA and pulmonary circulation • Increased hydrostatic pressure in pulmonary capillaries results in pulmonary edema Severe respiratory distress Chest x-ray for diagnosis Treatment • Decreased pulmonary hydrostatic pressure by treating LVF
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Copyright ©2020 F.A. Davis Company Pulmonary Embolism (PE) Clot that has traveled and lodged in pulmonary arterial circulation • Deep vein thrombosis (DVT) from lower extremity • Atrial thrombus Obstruction of blood flow to lung Presentation is vague, without warning Can lead to death Treatment • Anticoagulants, clot buster, inferior vena cava filter
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Copyright ©2020 F.A. Davis Company Pulmonary Hypertension Primary • Genetic disorder • Abnormal structure of pulmonary vessels Secondary • Increased pulmonary artery pressure as a result of other factors (i.e., hypoxemia) Diagnosis • X-ray, echocardiography, Doppler ultrasonography Treatment • Vasodilators
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Copyright ©2020 F.A. Davis Company Adult Respiratory Distress Syndrome (ARDS) Diffuse alveolar injury, pulmonary capillary damage, bilateral pulmonary infiltrates, and severe hypoxemia Seen in critically ill patients Sequela to trauma, sepsis, drug overdose, massive transfusion, acute pancreatitis, or aspiration Sepsis is most common risk factor Major cause of death
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Copyright ©2020 F.A. Davis Company Adult Respiratory Distress Syndrome (ARDS) (continued) Sudden, progressive pulmonary edema Arterial hypoxemia that does not improve with administration of oxygen ABG ’ s • Po 2 of 50 mm Hg or less • Pco 2 of 50 mm Hg or more Berlin criteria • Diagnostic conditions of ARDS Treatment • Mechanical ventilation
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