Obstructive Airway Diseases Slide 1 Copyright 2006 by

Emphysema Bronchitis Slide 2 Asthma Chronic obstructive pulmonary disease. Bronchitis, emphysema, and asthma may

Chapter 11 Chronic Bronchitis Chronic bronchitis. Inset, Weakened distal airways in emphysema, a common

Anatomic Alterations of the Lungs Excessive mucus production and accumulation Partial or total mucus plugging Hyperinflation of alveoli (air-trapping) Slide 4 Chronic inflammation and swelling of the peripheral airways Smooth muscle constriction of bronchial airways (bronchospasm) Copyright © 2006 by Mosby, Inc.

Etiology Slide 5 Cigarette smoking Atmospheric pollutants Infection Gastroesophageal reflux disease Copyright © 2006

Overview of the Cardiopulmonary Clinical Manifestations Associated with CHRONIC BRONCHITIS The following clinical manifestations result from the pathophysiologic mechanisms caused (or activated) by Excessive Bronchial Secretions (see Figure 9 -11) and Bronchospasm (see Figure 9 -10)—the major anatomic alterations of the lungs associated with chronic bronchitis (see Figure 11 -1). Slide 6 Copyright © 2006 by Mosby, Inc.

Figure 9 -11. Excessive bronchial secretions clinical scenario. Slide 7 Copyright © 2006 by

Figure 9 -10. Bronchospasm clinical scenario (e. g. , asthma). Slide 8 Copyright ©

Clinical Data Obtained at the Patient’s Bedside Vital signs Slide 9 Increased respiratory rate

Clinical Data Obtained at the Patient’s Bedside Use of accessory muscles of inspiration Use of accessory muscles of expiration Pursed-lip breathing Slide 10 Increased anteroposterior chest diameter (barrel chest) Cyanosis Digital clubbing Copyright © 2006 by Mosby, Inc.

Figure 2 -36. The way a patient may appear when using the pectoralis major

Figure 2 -41. A, Schematic illustration of alveolar compression of weakened bronchiolar airways during normal expiration in patients with chronic obstructive pulmonary disease (e. g. , emphysema). B, Effects of pursed-lip breathing. The weakened bronchiolar airways are kept open by the effects of positive pressure created by pursed lips during expiration. Slide 12 Copyright © 2006 by Mosby, Inc.

Digital Clubbing Figure 2 -46. Digital clubbing. Slide 13 Copyright © 2006 by Mosby,

Clinical Data Obtained at the Patient’s Bedside Peripheral edema and venous distention Slide 14

Distended Neck Veins Figure 2 -48. Distended neck veins (arrows). Slide 15 Copyright ©

Figure 2 -47. Pitting edema. From Bloom A, Ireland J: Color atlas of diabetes,

Clinical Data Obtained at the Patient’s Bedside Slide 17 Cough, sputum production, hemoptysis Chest assessment findings Ø Hyperresonant percussion note Ø Diminished breath sounds Ø Diminished heart sounds Ø Decreased tactile and vocal fremitus Ø Crackles/rhonchi/wheezing Copyright © 2006 by Mosby, Inc.

Figure 2 -12. Percussion becomes more hyperresonant with alveolar hyperinflation. Slide 18 Copyright ©

Slide 19 Figure 2 -17. As air trapping and alveolar hyperinflation develop in obstructive

Clinical Data Obtained from Laboratory Tests and Special Procedures Slide 20 Copyright © 2006

Pulmonary Function Study: Expiratory Maneuver Findings Slide 21 FVC FEVT FEF 25%-75% FEF 200

Pulmonary Function Study: Lung Volume and Capacity Findings VT RV FRC N or IC

Arterial Blood Gases Mild to Moderate Chronic Bronchitis Slide 23 Acute alveolar hyperventilation with

Time and Progression of Disease Onset Alveolar Hyperventilation 100 90 Pa. O 2 or Pa. CO 2 80 Point at which Pa. O 2 declines enough to stimulate peripheral oxygen receptors 70 60 Pa. O 2 50 40 30 20 Pa. C O 2 10 0 Slide 24 Figure 4 -2. Pa. O 2 and Pa. CO 2 trends during acute alveolar hyperventilation. Copyright © 2006 by Mosby, Inc.

Arterial Blood Gases Severe Chronic Bronchitis Chronic ventilatory failure with hypoxemia p. H Normal

Time and Progression of Disease Onset Alveolar Hyperventilation Chronic Ventilatory Failure 100 90 Pa 02 or Pa. C 02 80 70 60 Point at which Pa. O 2 declines enough to stimulate peripheral oxygen receptors Point at which disease becomes severe and patient begins to become fatigued O a. C 2 P 50 40 30 Pa O 2 20 10 0 Figure 4 -7. Pa. O 2 and Pa. CO 2 trends during acute or chronic ventilatory failure. Slide 26 Copyright © 2006 by Mosby, Inc.

Acute Ventilatory Changes Superimposed on Chronic Ventilatory Failure Slide 27 Acute alveolar hyperventilation on chronic ventilatory failure Acute ventilatory failure on chronic ventilatory failure Copyright © 2006 by Mosby, Inc.

Oxygenation Indices Slide 28 QS/QT DO 2 V O 2 C(a-v)O 2 Normal O

Hemodynamic Indices (Severe Chronic Bronchitis) Slide 29 CVP RAP PA PCWP Normal CO SV

Abnormal Laboratory Tests and Procedures Slide 30 Hematology Increased hematocrit and hemoglobin Electrolytes Ø Hypochloremia (chronic ventilatory failure) Ø Increased bicarbonate (chronic ventilatory failure) Sputum examination Ø Increased white blood cells Ø Streptococcus pneumoniae Ø Haemophilus influenzae Ø Moraxella catarrhalis Copyright © 2006 by Mosby, Inc.

Radiologic Findings Chest radiograph Slide 31 Translucent (dark) lung fields Depressed or flattened diaphragms

Figure 11 -2. Chest X-ray film of a patient with chronic bronchitis. Note the

Radiologic Findings Bronchogram Slide 33 Small spikelike protrusions Copyright © 2006 by Mosby, Inc.

Figure 11 -3. Chronic bronchitis. Bronchogram with localized view of left hilum. Rounded collections of contrast lie adjacent to bronchial walls and are particularly well seen below the left main stem bronchus (arrow) in this film. They are caused by contrast in dilated mucous gland ducts. (From Armstrong P, Wilson AG, Dee P: Imaging of diseases of the chest, St. Louis, 1990, Mosby. ) Slide 34 Copyright © 2006 by Mosby, Inc.

General Management of Chronic Bronchitis Patient and family education Behavioral management Slide 35 Ø Avoidance of smoking and inhaled irritants Ø Avoidance of infections Respiratory care treatment protocols Ø Oxygen therapy protocol Ø Bronchopulmonary hygiene therapy protocol Ø Aerosolized medication protocol Ø Mechanical ventilation protocol Copyright © 2006 by Mosby, Inc.

GOLD Standards Global Initiative for Chronic Obstructive Lung Disease Slide 36 Copyright © 2006

Figure 11 -4. Acute exacerbation of COPD (AECOPD): Guideline algorithm (ACCP/ACP-ASIM). CXR, Chest X-ray; NPPV, noninvasive positive pressure ventilation; PEFR, peak expiratory flow rate; URI, upper respiratory infection. (From GUIDELINES Pocketcard: Managing Chronic Obstructive Pulmonary Disease. Baltimore, 2004, Version 4. 0, International Guidelines Center. ) Slide 37 Copyright © 2006 by Mosby, Inc.

Figure 11 -4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic Obstructive Pulmonary Disease. Baltimore, 2004, Version 4. 0, International Guidelines Center. ) Slide 38 Copyright © 2006 by Mosby, Inc.

Figure 11 -4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic Obstructive Pulmonary Disease. Baltimore, 2004, Version 4. 0, International Guidelines Center. ) Slide 39 Copyright © 2006 by Mosby, Inc.

Figure 11 -4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic Obstructive Pulmonary Disease. Baltimore, 2004, Version 4. 0, International Guidelines Center. ) Slide 40 Copyright © 2006 by Mosby, Inc.

Figure 11 -4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic Obstructive Pulmonary Disease. Baltimore, 2004, Version 4. 0, International Guidelines Center. ) Slide 41 Copyright © 2006 by Mosby, Inc.

Figure 11 -4. Acute exacerbation of COPD (AECOPD): Guideline algorithm (ACCP/ACP-ASIM). CXR, Chest X-ray; NPPV, noninvasive positive pressure ventilation; PEFR, peak expiratory flow rate; URI, upper respiratory infection. (From GUIDELINES Pocketcard: Managing Chronic Obstructive Pulmonary Disease. Baltimore, 2004, Version 4. 0, International Guidelines Center. ) Slide 42 Copyright © 2006 by Mosby, Inc.