Copyright © 2006 by Mosby, Inc. Slide 1 PART II Obstructive Airway Diseases.

Copyright © 2006 by Mosby, Inc.Slide 1

PART IIPART II

Obstructive Airway DiseasesObstructive Airway Diseases


Chronic obstructive pulmonary disease.Chronic obstructive pulmonary disease.

Bronchitis, emphysema, and asthma may Bronchitis, emphysema, and asthma may present alone or in combination.present alone or in combination.

AsthmaBronchitis

Emphysema


Chapter 11 Chapter 11 Chronic BronchitisChronic Bronchitis

Chronic bronchitis. Chronic bronchitis. InsetInset, Weakened distal airways in emphysema, , Weakened distal airways in emphysema, a common secondary anatomic alteration of the lungsa common secondary anatomic alteration of the lungs..


Anatomic Alterations of the LungsAnatomic Alterations of the Lungs

Chronic inflammation and swelling of the Chronic inflammation and swelling of the peripheral airwaysperipheral airways

Excessive mucus production and Excessive mucus production and accumulationaccumulation

Partial or total mucus pluggingPartial or total mucus plugging

Hyperinflation of alveoli (air-trapping)Hyperinflation of alveoli (air-trapping)

Smooth muscle constriction of bronchial Smooth muscle constriction of bronchial airways (bronchospasm)airways (bronchospasm)


EtiologyEtiology

Cigarette smokingCigarette smoking

Atmospheric pollutantsAtmospheric pollutants

InfectionInfection

Gastroesophageal reflux diseaseGastroesophageal reflux disease


Overview of the Cardiopulmonary Overview of the Cardiopulmonary Clinical Manifestations Associated Clinical Manifestations Associated

with CHRONIC BRONCHITISwith CHRONIC BRONCHITIS

The following clinical manifestations result from The following clinical manifestations result from the pathophysiologic mechanisms caused (or the pathophysiologic mechanisms caused (or activated) by activated) by Excessive Bronchial SecretionsExcessive Bronchial Secretions (see Figure 9-11) and (see Figure 9-11) and BronchospasmBronchospasm (see (see Figure 9-10)—the major anatomic alterations of Figure 9-10)—the major anatomic alterations of the lungs associated with chronic bronchitis the lungs associated with chronic bronchitis (see Figure 11-1).(see Figure 11-1).


Figure 9-11. Excessive bronchial secretions clinical scenario.Figure 9-11. Excessive bronchial secretions clinical scenario.


Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).Figure 9-10. Bronchospasm clinical scenario (e.g., asthma).


Clinical Data Obtained at the Clinical Data Obtained at the Patient’s BedsidePatient’s Bedside

Vital signsVital signs

Increased respiratory rateIncreased respiratory rate

Increased heart rate, cardiac output, blood Increased heart rate, cardiac output, blood pressurepressure


Clinical Data Obtained at theClinical Data Obtained at the Patient’s Bedside Patient’s Bedside

Use of accessory muscles of inspirationUse of accessory muscles of inspiration

Use of accessory muscles of expirationUse of accessory muscles of expiration

Pursed-lip breathingPursed-lip breathing

Increased anteroposterior chest diameter Increased anteroposterior chest diameter (barrel chest)(barrel chest)

CyanosisCyanosis

Digital clubbingDigital clubbing


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


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


Digital Clubbing

Figure 2-46. Digital clubbing.Figure 2-46. Digital clubbing.



Peripheral edema and venous distentionPeripheral edema and venous distention

Distended neck veinsDistended neck veins

Pitting edemaPitting edema

Enlarged and tender liverEnlarged and tender liver


DistendedDistendedNeck VeinsNeck Veins

Figure 2-48. Distended neck veins (Figure 2-48. Distended neck veins (arrowsarrows).).


Figure 2-47. Pitting edema. From Bloom A, Ireland J: Figure 2-47. Pitting edema. From Bloom A, Ireland J: Color atlas of diabetesColor atlas of diabetes, ed 2,, ed 2,London, 1992, Mosby-Wolfe.London, 1992, Mosby-Wolfe.



Cough, sputum production, hemoptysisCough, sputum production, hemoptysis

Chest assessment findingsChest assessment findings Hyperresonant percussion noteHyperresonant percussion note

Diminished breath soundsDiminished breath sounds

Diminished heart soundsDiminished heart sounds

Decreased tactile and vocal fremitusDecreased tactile and vocal fremitus

Crackles/rhonchi/wheezingCrackles/rhonchi/wheezing


Figure 2-12. Figure 2-12. Percussion becomes more hyperresonant with alveolar hyperinflation.Percussion becomes more hyperresonant with alveolar hyperinflation.


Figure 2-17. Figure 2-17. As air trapping and alveolar hyperinflation develop in obstructive As air trapping and alveolar hyperinflation develop in obstructive lung diseases, breath sounds progressively diminish.lung diseases, breath sounds progressively diminish.


Clinical Data Obtained from Clinical Data Obtained from Laboratory Tests and Special Laboratory Tests and Special

ProceduresProcedures


Pulmonary Function Study: Pulmonary Function Study: Expiratory Maneuver FindingsExpiratory Maneuver Findings

FVCFVC FEVFEVTT FEFFEF25%-75%25%-75% FEFFEF200-1200200-1200

PEFRPEFR MVVMVV FEFFEF50%50% FEVFEV1%1%


Pulmonary Function Study: Pulmonary Function Study: Lung Volume and Capacity Findings Lung Volume and Capacity Findings

VVTT RV FRC TLC RV FRC TLC

N or N or N or N or

VCVC IC ERV RV/TLC ratio IC ERV RV/TLC ratio

N or N or

N or N or


Arterial Blood GasesArterial Blood Gases

Mild to Moderate Chronic BronchitisMild to Moderate Chronic Bronchitis

Acute alveolar hyperventilation with Acute alveolar hyperventilation with hypoxemiahypoxemia

pH PaCO2 HCO3- PaO2

(Slightly)


Time and Progression of Disease Time and Progression of Disease

100100

5050

3030

8080

00

PaCO2

1010

2020

4040

Alveolar HyperventilationAlveolar Hyperventilation

6060

7070

9090 Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

PaO2

Disease OnsetDisease OnsetP

aO2

or

PaC

O2

PaO

2 o

r P

aCO

2

Figure 4-2. PaO2 and PaCO2 trends during acute alveolar hyperventilation.


Arterial Blood GasesArterial Blood Gases

Severe Chronic BronchitisSevere Chronic Bronchitis

Chronic ventilatory failure with hypoxemiaChronic ventilatory failure with hypoxemia

pH PapH PaCOCO22 HCO HCO33-- Pa PaOO2 2

Normal Normal (Significantly)(Significantly)


Time and Progression of DiseaseTime and Progression of Disease

100100

5050

3030

80

0

PaO2

1010

2020

4040

Alveolar HyperventilationAlveolar Hyperventilation

6060

7070

9090Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

PaCO 2

Chronic Ventilatory Failure Chronic Ventilatory FailureDisease OnsetDisease Onset

Point at which disease becomes severe and patient begins to become fatigued

Point at which disease becomes severe and patient begins to become fatigued

Pa0

2 o

r P

aC0 2

Pa0

2 o

r P

aC0 2

Figure 4-7. PaO2 and PaCO2 trends during acute or chronic ventilatory failure.


Acute Ventilatory Changes Acute Ventilatory Changes Superimposed on Chronic Ventilatory Superimposed on Chronic Ventilatory

FailureFailure

Acute alveolar hyperventilation on chronic Acute alveolar hyperventilation on chronic ventilatory failureventilatory failure

Acute ventilatory failure on chronic Acute ventilatory failure on chronic ventilatory failureventilatory failure


Oxygenation IndicesOxygenation Indices

QQSS/Q/QTTDDOO22 VVOO22 C(a-v)C(a-v)OO22

NormalNormal NormalNormal

OO22ERER SvSvOO22


Hemodynamic Indices Hemodynamic Indices (Severe Chronic Bronchitis)(Severe Chronic Bronchitis)

CVP CVP RAPRAP PAPA PCWPPCWP

NormalNormal

COCO SVSV SVISVI CICI

NormalNormal NormalNormal NormalNormal Normal Normal

RVSWIRVSWI LVSWILVSWI PVRPVR SVRSVR

NormalNormal NormalNormal


Abnormal Laboratory Tests and Abnormal Laboratory Tests and ProceduresProcedures

Hematology Hematology Increased hematocrit and hemoglobinIncreased hematocrit and hemoglobin

Electrolytes Electrolytes Hypochloremia (chronic ventilatory failure)Hypochloremia (chronic ventilatory failure) Increased bicarbonate (chronic ventilatory failure)Increased bicarbonate (chronic ventilatory failure)

Sputum examinationSputum examination Increased white blood cellsIncreased white blood cells Streptococcus pneumoniaeStreptococcus pneumoniae Haemophilus influenzaeHaemophilus influenzae Moraxella catarrhalisMoraxella catarrhalis


Radiologic FindingsRadiologic Findings

Chest radiographChest radiograph

Translucent (dark) lung fieldsTranslucent (dark) lung fields

Depressed or flattened diaphragmsDepressed or flattened diaphragms

Long and narrow heartLong and narrow heart

Enlarged heartEnlarged heart


Figure 11-2. Chest X-ray film of a patient with chronic bronchitis. Note the translucent (dark) lung fields, depressed diaphragms, and long and narrow heart.


Radiologic FindingsRadiologic Findings

BronchogramBronchogram

Small spikelike protrusionsSmall spikelike protrusions


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.)


General Management of General Management of Chronic BronchitisChronic Bronchitis

Patient and family educationPatient and family education

Behavioral managementBehavioral management Avoidance of smoking and inhaled irritantsAvoidance of smoking and inhaled irritants

Avoidance of infectionsAvoidance of infections

Respiratory care treatment protocolsRespiratory care treatment protocols Oxygen therapy protocolOxygen therapy protocol

Bronchopulmonary hygiene therapy protocolBronchopulmonary hygiene therapy protocol

Aerosolized medication protocolAerosolized medication protocol

Mechanical ventilation protocolMechanical ventilation protocol


Global Initiative for Chronic

Obstructive

Lung

Disease

GOLD StandardsGOLD Standards


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.)


Figure 11-4. (Close-ups). (From GUIDELINES Pocketcard: Managing Chronic Obstructive Pulmonary Disease. Baltimore, 2004, Version 4.0, International Guidelines Center.)


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.)


Classroom DiscussionClassroom DiscussionCase Study: Chronic BronchitisCase Study: Chronic Bronchitis

Copyright © 2006 by Mosby, Inc. Slide 1 PART II Obstructive Airway Diseases.

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Transcript of Copyright © 2006 by Mosby, Inc. Slide 1 PART II Obstructive Airway Diseases.