Chapter 27 Alterations of Pulmonary Function Copyright 2017

Chapter 27 Alterations of Pulmonary Function Copyright © 2017, Elsevier Inc. All rights reserved.

Signs and Symptoms of Pulmonary Disease Dyspnea Subjective sensation of uncomfortable breathing Ø Orthopnea • Dyspnea when a person is lying down Ø Paroxysmal nocturnal dyspnea (PND) Ø Copyright © 2017, Elsevier Inc. All rights reserved. 2

Signs and Symptoms of Pulmonary Disease (Cont. ) Cough Acute cough Ø Chronic cough Ø Abnormal sputum Hemoptysis Abnormal breathing patterns: Kussmaul respirations (hyperpnea) Ø Cheyne-Stokes respirations Ø Copyright © 2017, Elsevier Inc. All rights reserved. 3

Signs and Symptoms of Pulmonary Disease (Cont. ) Hypoventilation Ø Hyperventilation Ø Hypercapnia Hypocapnia Cyanosis Clubbing Pain Copyright © 2017, Elsevier Inc. All rights reserved. 4

Clubbing Modified from Seidel HM et al: Mosby’s guide to physical examination, ed 7, St Louis, 2011, Mosby. Copyright © 2017, Elsevier Inc. All rights reserved. 5

Conditions Caused by Pulmonary Disease or Injury Hypercapnia Hypoxemia vs. hypoxia Ø Ventilation-perfusion abnormalities • Shunting Ø Acute respiratory failure Copyright © 2017, Elsevier Inc. All rights reserved. 6

Ventilation-Perfusion Copyright © 2017, Elsevier Inc. All rights reserved. 7

1. A patient has bulbous enlargement of the distal segments of the fingers. Which disease is associated with this condition? A. B. C. D. Cystic fibrosis Acute pneumonia Sickle cell disease Acute myocardial infarction Copyright © 2017, Elsevier Inc. All rights reserved. 8

Chest Wall Disorders Chest wall restriction Ø Compromised chest wall • Deformation, immobilization, and/or obesity Flail chest Ø Instability of a portion of the chest wall Copyright © 2017, Elsevier Inc. All rights reserved. 9

Flail Chest Copyright © 2017, Elsevier Inc. All rights reserved. 10

Pleural Abnormalities Pneumothorax Open pneumothorax Ø Tension pneumothorax Ø Spontaneous (primary) pneumothorax Ø Secondary pneumothorax Ø Copyright © 2017, Elsevier Inc. All rights reserved. 11

Pleural Abnormalities (Cont. ) Pleural effusion Transudative effusion Ø Exudative effusion Ø Hemothorax Ø Empyema • Infected pleural effusion; pus Ø Chylothorax Ø Copyright © 2017, Elsevier Inc. All rights reserved. 12

Pulmonary Disorders Restrictive lung diseases Aspiration • Passage of fluid and solid particles into the lungs Ø Atelectasis • Compression atelectasis • Absorption atelectasis • Surfactant impairment Ø Bronchiectasis • Persistent abnormal dilation of the bronchi Ø Copyright © 2017, Elsevier Inc. All rights reserved. 13

Absorption Atelectasis Copyright © 2017, Elsevier Inc. All rights reserved. 14

Pulmonary Disorders (Cont. ) Restrictive lung diseases Ø Bronchiolitis • Inflammatory obstruction of the small airways • Most common in children • Occurs in adults with chronic bronchitis, in association with a viral infection, or with inhalation of toxic gases Ø Pulmonary fibrosis • Idiopathic Copyright © 2017, Elsevier Inc. All rights reserved. 15

Pulmonary Disorders (Cont. ) Restrictive lung diseases (Cont. ) Ø Inhalation disorders: • Toxic gases • Pneumoconiosis Silica Asbestos Coal • Allergic alveolitis Extrinsic allergic alveolitis (hypersensitivity pneumonitis) – Allergic reaction from inhaled particles or fumes Copyright © 2017, Elsevier Inc. All rights reserved. 16

Pulmonary Disorders (Cont. ) Restrictive lung diseases (Cont. ) Ø Pulmonary edema • Excess water in the lungs Copyright © 2017, Elsevier Inc. All rights reserved. 17

Pulmonary Edema Copyright © 2017, Elsevier Inc. All rights reserved. 18

Pulmonary Disorders Restrictive lung diseases (Cont. ) Ø Acute lung injury (ALI)/Acute respiratory distress syndrome (ARDS) • Characterized by acute lung inflammation and diffuse alveolocapillary injury • Injury and inflammation to the alveocapillary membrane Pulmonary edema • Three phases: Exudative Proliferative Fibrotic Copyright © 2017, Elsevier Inc. All rights reserved. 19

Pulmonary Disorders (Cont. ) Restrictive lung diseases (Cont. ) Ø Acute lung injury (ALI)/Acute respiratory distress syndrome (ARDS) (Cont. ) • Manifestations: Dyspnea and hypoxemia Hyperventilation and respiratory alkalosis Decreased tissue perfusion, metabolic acidosis, and organ dysfunction Increased work of breathing, decreased tidal volume, and hypoventilation Hypercapnia, respiratory acidosis Respiratory failure, decreased cardiac output, hypotension, and death Copyright © 2017, Elsevier Inc. All rights reserved. 20

Pulmonary Disorders (Cont. ) Acute lung injury (ALI)/Acute respiratory distress syndrome (ARDS) (Cont. ) Diagnosis is based on a history of the lung injury, physical examination, analysis of blood gases, and radiologic examination Ø Supportive therapy Ø Copyright © 2017, Elsevier Inc. All rights reserved. 21

2. Which of the following is TRUE regarding Acute respiratory distress syndrome (ARDS)? A. It is caused by injury to the bronchioles. B. It can cause severe pulmonary edema. C. It is most commonly caused by exposure to inhaled irritants. D. Macrophages are not involved in response. Copyright © 2017, Elsevier Inc. All rights reserved. 22

Pulmonary Disorders (Cont. ) Obstructive lung diseases Airway obstruction that is worse with expiration Ø Common signs and symptoms • Dyspnea and wheezing Ø Common obstructive disorders • Asthma • COPD • Emphysema • Chronic bronchitis Ø Copyright © 2017, Elsevier Inc. All rights reserved. 23

Asthma Copyright © 2017, Elsevier Inc. All rights reserved. 24

Pulmonary Disorders (Cont. ) Obstructive lung diseases: Asthma Chronic inflammatory disorder of the airways Ø Inflammation results from hyperresponsiveness of the airways Ø Can lead to obstruction and status asthmaticus Ø Symptoms include expiratory wheezing, dyspnea, and tachypnea Ø Peak flow meters, corticosteroids, beta agonists, and anti-inflammatories used to treat Ø Copyright © 2017, Elsevier Inc. All rights reserved. 25

Pulmonary Disorders (Cont. ) Obstructive lung diseases: COPD Characterized by persistent airflow limitation Ø Usually progressive Ø Most common chronic lung disease in world Ø Risk factors • Tobacco smoke • Occupational dusts and chemicals • Air pollution • Any factor affecting lung growth during gestation and Ø childhood Copyright © 2017, Elsevier Inc. All rights reserved. 26

Chronic Obstructive Pulmonary Disease Copyright © 2017, Elsevier Inc. All rights reserved. 27

Chronic Obstructive Pulmonary Disease (Cont. ) Copyright © 2017, Elsevier Inc. All rights reserved. 28

Pulmonary Disorders (Cont. ) Obstructive lung diseases: Chronic bronchitis Hypersecretion of mucus and chronic productive cough that lasts for at least 3 months of the year and for at least 2 consecutive years Ø Inspired irritants increase mucus production and the size and number of mucous glands Ø The mucus is thicker than normal Ø Bronchodilators, expectorants, and chest physical therapy used to treat Ø Copyright © 2017, Elsevier Inc. All rights reserved. 29

Pulmonary Disorders (Cont. ) Obstructive lung diseases: Emphysema Abnormal permanent enlargement of the gasexchange airways accompanied by destruction of alveolar walls without obvious fibrosis Ø Inherited deficit of α 1 -antitrypsin Ø Loss of elastic recoil Ø Copyright © 2017, Elsevier Inc. All rights reserved. 30

3. Which of the following is TRUE regarding the pathophysiology of asthma? A. B. C. D. Ig. A is the major factor. There is decreased vascular permeability. Inflammation results in hyperresponsiveness. The inflammatory process is caused by the loss of bronchial smooth muscle spasm. Copyright © 2017, Elsevier Inc. All rights reserved. 31

Pulmonary Disorders (Cont. ) Respiratory tract infections: Acute bronchitis Acute infection or inflammation of the airways or bronchi Ø Commonly follows a viral illness Ø Acute bronchitis causes symptoms similar to those of pneumonia but does not demonstrate pulmonary consolidation and chest infiltrates Ø Copyright © 2017, Elsevier Inc. All rights reserved. 32

Pulmonary Disorders (Cont. ) Respiratory tract infections: Pneumonia Lower respiratory tract infection Ø Caused by bacteria, viruses, fungi, protozoa, or parasites Ø Healthcare acquired (HCAP) or community acquired (CAP) Ø Copyright © 2017, Elsevier Inc. All rights reserved. 33

Pulmonary Disorders (Cont. ) Respiratory tract infections: Pneumonia (Cont. ) Pneumococcal • Most common and most lethal • Intense inflammatory response Ø Viral • Seasonal and usually self-limiting Ø Usually preceded by viral URI Ø Copyright © 2017, Elsevier Inc. All rights reserved. 34

Pneumococcal Pneumonia Copyright © 2017, Elsevier Inc. All rights reserved. 35

Pulmonary Disorders (Cont. ) Respiratory tract infections Ø Tuberculosis • Mycobacterium tuberculosis • Acid-fast bacillus • Airborne transmission • Tubercle formation • Caseous necrosis • Positive tuberculin skin test (PPD) Copyright © 2017, Elsevier Inc. All rights reserved. 36

Pulmonary Disorders (Cont. ) Abscess formation and cavitation Abscess Ø Consolidation Ø Cavitation Ø Copyright © 2017, Elsevier Inc. All rights reserved. 37

Pulmonary Disorders (Cont. ) Pulmonary vascular disorders: Pulmonary embolus Occlusion of a portion of the pulmonary vascular bed by a thrombus, embolus, tissue fragment, lipids, or an air bubble Ø Pulmonary emboli commonly arise from the deep veins in the lower leg Ø Virchow triad • Venous stasis, hypercoagulability, and injuries to the Ø endothelial cells that line the vessels Copyright © 2017, Elsevier Inc. All rights reserved. 38

Pulmonary Embolism Copyright © 2017, Elsevier Inc. All rights reserved. 39

Pulmonary Disorders (Cont. ) Pulmonary vascular disorders: Pulmonary artery hypertension Mean pulmonary artery pressure 5 to 10 mm Hg above normal or above 20 mm Hg Ø Primary pulmonary hypertension • Idiopathic Ø Diseases of the respiratory system and hypoxemia are more common causes Ø Copyright © 2017, Elsevier Inc. All rights reserved. 40

Pulmonary Disorders (Cont. ) Pulmonary vascular disorders: Pulmonary artery hypertension (Cont. ) Ø Classifications: • Pulmonary arterial hypertension • Pulmonary venous hypertension • Pulmonary hypertension due to a respiratory disease or hypoxemia • Pulmonary hypertension due to thrombotic or embolic disease • Pulmonary hypertension due to diseases of the pulmonary vasculature Copyright © 2017, Elsevier Inc. All rights reserved. 41

Pulmonary Hypertension Copyright © 2017, Elsevier Inc. All rights reserved. 42

Pulmonary Disorders (Cont. ) Pulmonary vascular disorders: Cor pulmonale Ø Pulmonary heart disease • Right ventricular enlargement • Secondary to pulmonary hypertension • Pulmonary hypertension creates chronic pressure overload in the right ventricle Copyright © 2017, Elsevier Inc. All rights reserved. 43

Pulmonary Disorders (Cont. ) Malignancies of the respiratory tract Ø Laryngeal • Forms: Carcinoma of the true vocal cords (most common) Supraglottic Subglottic rare Copyright © 2017, Elsevier Inc. All rights reserved. 44

Laryngeal Cancer Redrawn from del Regato JA et al: Ackerman and del Regato’s cancer, ed 2, St Louis, 1985, Mosby. Copyright © 2017, Elsevier Inc. All rights reserved. 45

Pulmonary Disorders (Cont. ) Malignancies of the respiratory tract Ø Lung (bronchogenic) • Most common cause is cigarette smoking • Heavy smokers have a 20 -times greater chance of developing lung cancer than nonsmokers • Smoking is related to cancers of the larynx, oral cavity, esophagus, and urinary bladder • Environmental or occupational risk factors are also associated Copyright © 2017, Elsevier Inc. All rights reserved. 46

Pulmonary Disorders (Cont. ) Malignancies of the respiratory tract (Cont. ) Ø Lung • Types: Non–small cell cancer: – Squamous cell carcinoma – Adenocarcinoma – Large cell carcinoma Small cell cancer—from neuroendocrine tissue Copyright © 2017, Elsevier Inc. All rights reserved. 47

4. A patient has right ventricular enlargement secondary to pulmonary hypertension. Which of the following would be the most likely diagnosis? A. B. C. D. Cor pulmonale Acute bronchitis Pulmonary embolism Pulmonary thromboembolism Copyright © 2017, Elsevier Inc. All rights reserved. 48