Ch22 Obstructive pulmonary disorders

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wvuong
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298671
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Ch22 Obstructive pulmonary disorders
Updated:
2015-03-18 17:48:11
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pulmonary
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patho
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obstructive pulmonary disorders
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  1. obstructive pulmonary disorders
    manifested by increased resistance to airflow
  2. classifications of obstructive pulmonary disorders
    • obstruction from conditions in the wall of the lumen 
    • obstruction resulting from increasing pressure around the outside of the airway lumen 
    • obstruction of the airway lumen
  3. Asthma 
    [etiology]
    • airway obstruction that is reversible (not completely in some patients) 
    • airway inflammation 
    • increased airway responsiveness to a variety of stimuli
  4. Asthma 
    [predisposing factors]
    • genetic for atopy and structural (smaller airways) - chromosomes 5, 11, 14
    • history of hay fever, eczema
    • fam. history
    • positive skin test reactions to allergens
  5. Asthma
    [extrinsic - allergic]
    IgE mediated response - common
  6. Asthma 
    [clinical manifestations]
    • elevated IgE lvls 
    • allergic rhinitis 
    • eczema
    • positive fam history of allergy 
    • attacks associated with seasonal, environment, or occupational exposure
  7. Asthma
    extrinsic - mechanism of action - immediate phase
    • initiated by exposure to specific antigen that has previously sensitized mast cells in airway mucosa
    • antigen reacts with antibody on surface of mast cell 
    • mast cell releases packets of chemical mediator substances
  8. Asthma - Extrinsic 
    Mechanism of action 
    What are the chemical mediators released?
    • histamine
    • slow-reacting substances of anaphylaxis (leukotrienes)
    • prostaglandins
    • bradykinins
    • eosinophilic chemotactic factor 
    • serotonin
  9. Asthma 
    extrinsic - mechanism of action
    • normal respiratory epithelium is denuded and replaced by goblet cells 
    • alterations in epithelial integrity
  10. Asthma - Extrinsic 
    mechanism of action 
    What increased microvascular permeability
    • mucosal edema 
    • inflammatory exudates 
    • bronchoconstriction 
    • leakage
  11. Asthma 
    [causes]
    • Acute bronchospasm (bronchoconstriction)
    • mucosal edema
    • mucous plug formation 
    • airway wall remodeling
  12. Asthma 
    [common symptoms]
    • wheezing 
    • feeling of tightness of chest 
    • dyspnea
    • cough (dry/productive) 
    • increased sputum production (thick, tenacious, scant, and viscid)
  13. Asthma 
    [symptoms of severe attack]
    • use of accessory muscles of respiration
    • intercostal retractions 
    • distant breath sounds w/ inspiratory wheezing 
    • orthopnea
    • agitation
    • tachypnea
    • tachycardia
  14. Asthma 
    [diagnosis]
    • physical findings: 
    • cough
    • wheezing 
    • hyperinflated chest 
    • decreased breath sounds

    radiographic finding: hyperinflation with flattening of the diaphragm

    • sputum exam: 
    • charcot-leyden crystals (formed from crystallized enzymes fr. eosinophilic membranes)
    • Eosinophils 
    • Curschmann spirals (mucous casts of bronchioles)

    • ABG: 
    • normal during mild attack 
    • respiratory alkalosis and hypoxemia as bronchospasm increases in intensity 
    • PaCO2 elevation
  15. Asthma 
    [Treatment]
    • avoid triggers 
    • environmental control 
    • preventive therapy 
    • desensitization (allergen specific immunotherapy)

    • Meds: 
    • O2 therapy
    • small-volume nebulizers 
    • B2 agonists 
    • Corticosteroids 
    • leukotriene modifiers 
    • mast cell inhibitors
  16. Acute bronchitis 
    [etiology]
    acute inflammation of trachea and bronchi 

    • viral: influenza virus A/B
    • parainfluenza virus 
    • respiratory syncytial virus 
    • coronavirus 
    • rhinovirus 
    • coxsackievirus
    • adenovirus

    • Nonviral: 
    • strept. pneumoniae
    • haemophilus influenzae
    • Mycoplasma
    • moraxella
    • chlamydia pneumoniae

    • Causes: 
    • heat/burn
    • smoke inhalation 
    • inhalation of irritant chemicals 
    • allergic reactions
  17. Acute bronchitis 
    [pathogenesis]
    • Airways become inflamed and narrowed from capillary dilation 
    • swelling from exudation of fluid 
    • infiltration with inflammatory cells increased mucus production 
    • loss of ciliary function 
    • loss of portions of ciliated epithelium
  18. Acute bronchitis 
    [clinical manifestations]
    • cough (productive/nonproductive)
    • low grade fever 
    • substernal chest discomfort 
    • sore throat 
    • postnasal drip 
    • fatigue
  19. Acute bronchitis 
    [diagnosis]
    • clinical presentation 
    • chest xray to distinguish acute bronchitis from pneumonia (typically an acute bronchitis will have a normal CXR)
  20. Acute bronchitis 
    [treatment]
    • antibiotic therapy (bacterial) 
    • codeine - containing meds (for cough)
    • increase fluid intake 
    • avoid smoke 
    • use a vaporizer in bedroom
  21. Chronic Bronchitis 
    [etiology]
    • Type B COPD 'blue bloater'
    • Chronic/recurrent productive cough >3 mos >2+ yrs
    • persistent, irreversible 
    • typical pt is overweight
    • 30-40 yrs 
    • commonly assoc. w/ emphysema
  22. Chronic Bronchitis 
    [cause]
    • cigarette smoking 
    • repeated airway infections 
    • genetic predisposition 
    • inhalation of physical or chemical irritants
  23. Chronic Bronchitis 
    [pathogenesis]
    • chronic inflammation and swelling of the bronchial mucosa resulting in scarring 
    • hyperplasia of bronchial mucous gland/goblet cells (^mucus production)
    • increased bronchial wall thickness
    • pulmonary hypertension
  24. Chronic inflammation and swelling of the bronchial mucosa resulting in scarring means what? 
    [Chronic Bronchitis]
    • elevated IL8 levels recruit neutrophil activation 
    • elevated CD8 T lymphocytes 
    • extend into surrounding alveoli 
    • prevent proper oxygenation andp otentiate airway obstruction
  25. Hyperplasia of bronchial mucous gland/goblet cells means ... [chronic bronchitis]
    • increased mucus production 
    • mucus combines with purulent exudate (bronchial plugs) to form mucous plug
  26. increased bronchial wall thickness means.. [chronic bronchitis]
    • resistance increases work of breathing
    • increased O2 demands 
    • produce ventilation-perfusion mismatch with hypoxemia and hypercarbia (increases pulmonary artery resistance)
  27. Pulmonary hypertension means... [chronic bronchitis]
    • inflammation in bronchial walls with vasoconstriction of pulmonary blood vessels and pulmonary arteries 
    • R-sided heart failure may occur r/t high pulmonary resistance
  28. Chronic bronchitis 
    [Clinical manifestations]
    • SOB on exertion 
    • excessive sputum 
    • chronic cough (more severe in mornings) 
    • evidence of excess body fluids (edema, hypervolemia) 
    • Cyanosis (late sign)
  29. Chronic Bronchitis 
    [Diagnosis]
    • Chest xray: 
    • increased bronchial vascular markings 
    • congested lung fields 
    • enlarged horizontal cardiac silhouette
    • evidence of previous pulmonary infection 

    • PFT: 
    • normal total lung capacity (TLC)
    • increased residual volume (RV)
    • decreased FEV1

    • ABG:
    • Elevated PaCO2
    • Decreased PO2
    • Develop early in disease process
  30. Chronic Bronchitis
    [Treatment]
    • Meds: 
    • inhaled short-acting B2 agonists 
    • inhaled anticholinergic bronchodilators 
    • cough suppressants 
    • antimicrobial agents (bacterial infections) 
    • inhaled/oral corticosteroids 
    • theophylline products 
    • low-dose O2 therapy for patients with PaO2 levels <55mmHg
  31. Chronic Bronchitis
    [management]
    • stop smoking 
    • bronchodilator therapy
    • reduction to exposure of irritants 
    • adequate rest 
    • proper hydration 
    • physical reconditioning
  32. Emphysema 
    [Etiology]
    • Type A COPD
    • "pink puffer" 
    • young to middle age adults <50yrs (uncommon)
    • ----Hereditary low α1-antitrypsin activity in lung 
    • >50 yrs (develops over time)

    • Smoking >70 pack/year
    • Air pollution 
    • certain occupations 
    • α1-Antitrypsin deficiency

    smoking causes alveolar damage
  33. Smoking causes alveolar damage 
    [What happens]
    • inflammation in lung tissue leading to release of proteolytic enzymes 
    • inactivates α1-antitrypsin (protects lung parenchyma)
  34. Emphysema 
    [Pathogenesis]
    • Loss of elastic tissue in lung 
    • ---results in decrease in size of smaller bronchioles 
    • ---results in loss of radial traction (holds airway open)
  35. Emphysema 
    [clinical manifestations]
    • Progressive, exertional dyspnea
    • increased SOB for past 3-4 yrs 
    • Thin (r/t increased caloric expenditure and decreased ability to consume adequate calories) 
    • use of accessory muscles 
    • pursed-lip breathing 
    • cough (minimal or absent)
  36. Emphysema
    [diagnosis]
    • patient history and physical finding 
    • -thin,wasted individual hunched forward
    • barrel chest 
    • digital clubbing 
    • decreased breath sounds, lack of crackles and bronchi with prolonged expiration
    • decreased heart sounds 
    • decreased diaphragmatic excursion

    • chest xray 
    • hyperventilation
    • low, flat diaphragm
    • presence of blebs or bullae 
    • narrow mediastinum
    • normal/small 'vertical' heart
  37. Emphysema
    [treatment]
    • O2 therapy
    • meds: 
    • -inhaled short-acting B2 agonists 
    • -inhaled anticholinergic bronchodilators 
    • cough suppressants 
    • antimicrobial agents (infections) 
    • inhaled/oral corticosteroids 
    • theophylline products
  38. Cystic fibrosis 
    [etiology]
    • Autosomal recessive disorder of exocrine glands (dysfunction of CFTR gene)
    • affects pancreas, intestinal tract, sweat glands, lungs, infertility (male)
  39. Cystic Fibrosis 
    [clinical manifestations]
    • history of cough in young adult/child 
    • thick, tenacious sputum 
    • recurrent pulmonary infections/episodes of bronchitis

    • physical findings: 
    • digital clubbing 
    • dyspnea, tachypnea
    • sternal retractions 
    • unequal breath sounds 
    • moist basilar crackle and rhonchi
    • barrel chest hyperresonant to percussion

    • Nutritional assessment: 
    • Depleted fat stores 
    • steatorrhea (fatty stools) 
    • anorexia 
    • decreased growth rate in children (wt, ht, head circ) 
    • decreased mid-arm indices
  40. Cystic fibrosis 
    [treatment]
    • postural drainage and chest physiotherapy
    • meds: 
    • ---bronchodilators 
    • ---high dose antibiotics (bacterial infections) 
    • ---influenza vaccine 
    • heart lung or lung transplant
    • Nutritional therapy: 
    • ---unrestricted fat consumption 
    • ---high protein
    • ---vitamin supplements 
    • ---pancreatic enzymes 
    • ---intake of 150% normal caloric intake
  41. Acute Tracheobronchial obstruction
    [etiology]
    • aspiration of foreigh body (L lung) 
    • malpositioned endotracheal tube 
    • laryngospasm
    • Epiglottitis
    • Trauma
    • swelling (smoke inhalation) 
    • postsurgical blood clot 
    • compression of bronchus/trache (tumor, enlarged lymph nodes
  42. Acute Tracheobronchial obstruction 
    [clinical obstruction]
    partial obstruction
    • stridor 
    • sternal and intercostal retractions 
    • wheezing 
    • nasal flaring 
    • tachypnea, dyspnea
    • Tachycardia 
    • Use of accessory muscles
  43. Acute tracheobronchial obstruction 
    [clinical manifestations] 
    complete obstruction (emergency)
    • no air movement w/ auscultation 
    • inability to talk 
    • tachycardia
    • cyanosis 
    • rapid progression to unconsciousness
  44. Acute tracheobronchial obstruction 
    [treatment]
    • open obstructed airway asap
    • Heimlich
    • Emergency tracheostomy
  45. Epiglottitis 
    [Etiology]
    • Rapidly, progressive cellulitis of epiglottis and adjacent soft tissues 
    • subtype of croup 
    • children 2-4 yrs 
    • Common organisms (Pneumococci, Streptococci, staphylococci)
  46. Epiglottitis
    [pathogenesis]
    • infecting agent localizes in epiglottis and pharyngeal structures 
    • causes rapid and potentially fatal inflammation (Swelling and airway obstruction)
  47. Epiglottitis 
    [clinical manifestations]
    • drooling
    • dysphagia, dysphonia
    • rapid onset of fever 
    • inspiratory stridor and retractions 
    • oropharynx edematous and cherry red 
    • child sits in 'sniffing dog' position (provides best airway patency)
  48. Epiglottitis 
    [treatment]
    • true medical emergency
    • may necessitate intubation
    • antibiotic therapy
    • preventative (Hib vaccine)
  49. Croup Syndrome 
    [etiology]
    • number of acute, viral inflammatory disease of larynx, trachea, and bronchi
    • --laryngotracheobronchitis
    • --epiglottitis
    • --bacterial tracheitis

    • Causes: 
    • parainfluenza virus type 2 and 3 
    • RSV 
    • influenzavirus 
    • Adenovirus 
    • Mycoplasma pneumoniae
  50. Croup syndrome
    [pathogenesis]
    • viral agent of subglottic area
    • infectious agent causes inflammation along entire airway
    • leads to edema in subglottic area
  51. Croup syndrome 
    [clinical manifestations]
    • history of upper respiratory infection or cold
    • barking cough with stridor 
    • low grade fever (may be absent)
    • Severe cases: stridor at rest, retractions, cyanosis
  52. Croup syndrome 
    [treatment]
    • mist therapy
    • oral hydration 
    • avoidance of stimulation 
    • O2 therapy, pulse oximetry (hospitalized)
    • nebulized epinephrine (relieves airway obstruction) 
    • endotracheal intubation (respiratory failure)

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